Knowledge Key:
Arguments against Arguments againste
Arguments for Arguments for
Prospect Recommendation Prospect Recommendation
Clinical Practice Clinical Practice
Transferable Evidence Transferable Evidence
Procedure Specific Evidence Procedure Specific Evidence

Intra-Operative

Expand all

Systemic Analgesia

PROSPECT Recommendations

  • Conventional NSAIDs are not recommended during the procedure in thoracotomy due to the risk of bleeding (transferable evidence, Grade B). However, see Postoperative conventional NSAIDs.

Clinical Practice

  • Caution is required when conventional NSAIDs are used in patients receiving epidural analgesia concomitantly with medications for thromboprophylaxis, due to the risk of spinal haematoma

Transferable Evidence

  • Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures Barden et al 2004
  • A meta-analysis of randomised controlled trials that was performed to evaluate the risk of morphine-related adverse effects in patients treated with NSAIDs demonstrated that NSAIDs decreased the incidence of nausea, vomiting and sedation, but not pruritis, urinary retention or respiratory depression Marret et al 2005
  • Randomised trials in healthy volunteers have shown that conventional NSAIDs are associated with a higher incidence of upper gastrointestinal ulceration compared with COX-2 selective inhibitors for short-term use Harris et al 2001
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with control Marret et al 2003
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused reversible platelet dysfunction Niemi et al 1997
  • A large randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease Stevenson 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2003

Thoracotomy-specific Evidence

PROSPECT Recommendations

  • COX-2-selective inhibitors are not recommended intra-operatively because there is a lack of procedure-specific evidence that intra-operative administration is of more benefit than postoperative administration (Grade D); see Postoperative COX-2-selective inhibitors.

Clinical Practice

  • The potential side-effects of pre- or intra-operative COX-2-selective inhibitors may have greater consequences in this procedure, due to the typically poor condition of the patient, due to potential for greater blood and fluid loss, and renal complications
  • Thoracic surgery patients may frequently have coronary artery disease or cardiac contra-indications

Transferable Evidence from Other Procedures

  • COX-2-selective inhibitors provide similar postoperative analgesia to conventional NSAIDs Rømsing et al 2004
  • Randomised trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation Greenberg et al 2000
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function Bavbek et al 2004
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following noncardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) Nussmeier et al 2006
  • Two clinical trials showed that in patients who had undergone CABG surgery COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo Nussmeier et al 2005
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents EMEA 2004a
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting Blomme et al 2003
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2003

Thoracotomy-specific Evidence

  • None cited

PROSPECT Recommendations

  • Low-dose ketamine cannot be recommended at this time due to a lack of procedure-specific evidence (Grade D), although analgesic data from other procedures are promising

Clinical Practice

  • Ketamine may be of benefit for prevention of chronic pain conditions following thoracotomy, where 40–60% patients may develop chronic pain and/or allodynia. Additionally, it may be of benefit in patients who have opioid tolerance. Ketamine is most often used after induction of GA, but before incision (pre-operatively)

Transferable Evidence

  • Studies of intravenous or neuraxial ketamine in a variety of surgeries, including abdominal, gynaecological, orthopaedic, gastric, hepatic, and genito-urinary surgery, showed a reduction in postoperative pain and opioid use when used as an adjunct to morphine Bell et al 2005

Thoracotomy-specific Evidence

  • None cited

PROSPECT Recommendations

  • Gabapentin/pregabalin cannot be recommended at this time due to a lack of procedure-specific evidence (Grade D), although analgesic data from other procedures are promising

Clinical Practice

  • Gabapentin may be of benefit for prevention of chronic pain conditions following thoracotomy, where 40–60% of patients may develop chronic pain and/or allodynia

Transferable Evidence

  • Studies of gabapentin and pregabalin in mastectomy, abdominal surgery, laparoscopic cholecystectomy, spinal surgery, knee surgery, ear-nose-throat surgery, and nephrectomy showed reductions in postoperative pain and supplementary analgesic requirements for at least 24 h Dahl et al 2004
  • One study showed no significant benefit of gabapentin 800 mg for reducing pain or opioid use compared with placebo in spinal surgery (n=60) Radhakrishnan et al 2005

Thoracotomy-specific Evidence

  • None cited

Epidural Analgesia

PROSPECT Recommendations

  • Intra-operative thoracic epidural LA plus strong opioid is recommended based on a reduction in pain compared with postoperative administration alone (Grade A)
  • Intra-operative thoracic epidural LA plus strong opioid is recommended as an infusion continued for 2–3 days postoperatively, based on a reduction in pain compared with systemic analgesia (Grade A, see Postoperative Epidural Analgesia)
  • There are not enough data to recommend one specific combination of LA and opioid over another
  • There are not enough data to recommend a specific concentration or volume of LA and strong opioid
  • There are not enough data to recommend lipophilic opioids in preference to hydrophilic opioids or vice versa, in combination with LA

Clinical Practice

  • Thoracic epidural strong opioid alone may be used when there is a contra-indication for thoracic epidural LA, such as hypotension due to excessive blood loss
  • Thoracic epidural LA alone may be used when opioid-associated side-effects are a problem
  • Use of heparin or conventional NSAIDs may increase the risk of spinal haematoma due to epidural analgesia

Transferable Evidence

  • A meta-analysis of randomised controlled trials found that both continuous epidural infusion and PCEA analgesia provided superior postoperative analgesia compared with intravenous PCA analgesia Wu et al 2005
  • A meta-analysis found that continuous epidural infusion provided superior analgesia and reduced the incidence of pruritis compared with PCEA analgesia, but was associated with a higher incidence of PONV and motor block Wu et al 2005
  • A meta-analysis of randomised controlled trials found that epidural analgesia significantly decreased the incidence of pulmonary morbidity compared with systemic opioids Ballantyne et al 1998 Click here for more information
  • Epidural administration of strong opioids is associated with side effects including pruritis, PONV, urinary retention, and respiratory depression Chaney 1995

Thoracotomy-specific Evidence

  • Four of six studies showed that pre-/intra-operative thoracic epidural LA ± strong opioid reduced pain scores compared with control Neustein et al 2002 Click here for more information
  • Two studies reported that pre-/intra-operative thoracic epidural bupivacaine plus morphine was similar to control for the incidence of: vomiting (all patients received postoperative epidural analgesia) (n=46) Senturk et al 2002
  • Three of five studies reported that pre-/intra-operative thoracic epidural LA ± strong opioid was similar to control for the rate of epidural infusion required or indomethacin use Aguilar et al 1996 Click here for more information
  • Intra-operative plus postoperative thoracic epidural bupivacaine plus fentanyl was not associated with an increase in physical activity after discharge compared with postoperative epidural alone (n=120) Ochroch et al 2002
  • Study details Aguilar et al 1996 Click here for more information

PROSPECT Recommendations

  • Lumbar epidural strong opioid is not recommended as the first choice of epidural technique, based on evidence that the thoracic epidural route is more effective for pain relief following thoracotomy (Grade A, see Postoperative Epidural Analgesia). However, there is procedure-specific evidence that lumbar epidural hydrophilic strong opioid reduces pain compared with systemic analgesia (see Postoperative Epidural Analgesia)

Clinical Practice

  • Infusion techniques are more convenient for use in clinical practice and adequate analgesia is more likely to be maintained than with bolus administration of lumbar epidural strong opioid
  • Use of heparin or conventional NSAIDs may increase the risk of spinal haematoma due to epidural analgesia

Transferable Evidence

  • A meta-analysis of randomised controlled trials found that both continuous epidural infusion and PCEA analgesia provided superior postoperative analgesia compared with intravenous PCA analgesia Wu et al 2005
  • A meta-analysis found that continuous epidural infusion provided superior analgesia and reduced the incidence of pruritis compared with PCEA analgesia, but was associated with a higher incidence of PONV and motor block Wu et al 2005
  • A meta-analysis of randomised controlled trials found that epidural analgesia significantly decreased the incidence of pulmonary morbidity compared with systemic opioids Ballantyne et al 1998 Click here for more information
  • Epidural administration of strong opioids is associated with side effects including pruritis, PONV, urinary retention, and respiratory depression Chaney 1995

Thoracotomy-specific Evidence

  • Intra-operative lumbar epidural morphine injection was superior to all concentrations of nalbuphine for reducing pain scores Baxter et al 1991 Click here for more information
  • Intra-operative lumbar epidural morphine injection was superior to all concentrations of nalbuphine for reducing PCA fentanyl use (p<0.01) (five treatment arms; n=52) Baxter et al 1991
  • One study showed that morphine 0.67 mg/ml and nalbuphine 0.5, 1, 1.5 and 2 mg/ml, for intra-operative lumbar epidural injection, were associated with a similar incidence of nausea (five treatment arms; n=52) Baxter et al 1991
  • Intra-operative lumbar epidural nalbuphine injection was superior to morphine for reducing the proportion of patients requiring naloxone, and nalbuphine was associated with a lower mean PaCO2 Baxter et al 1991 Click here for more information
  • Nalbuphine 1.5 mg/ml was superior to nalbuphine 0.5, 1 and 2 mg/ml lumbar epidural (p<0.01) for reducing total pain scores over the 24-h study period (four treatment arms; n=40) Baxter et al 1991
  • Nalbuphine 2 mg/ml was superior to nalbuphine 0.5, 1 and 1.5 mg/ml lumbar epidural (p<0.01) for reducing the 24-h dose of fentanyl Baxter et al 1991 Click here for more information
  • Intra-operative lumbar epidural nalbuphine 0.5, 1, 1.5 and 2 mg/ml were similar for blood gas levels (four treatment arms; n=40) Baxter et al 1991
  • Post-incisional administration of lumbar epidural fentanyl was inferior to pre-incisional administration for reducing pain scores Katz et al 1992 Click here for more information
  • Study details Baxter et al 1991 Click here for more information

PROSPECT recommendations

  • Thoracic epidural corticosteroid is not recommended because there are limited data (Grade D)
  • Epidural epinephrine is recommended if a low dose of epidural LA and/or opioid is used (Grade B)

Clinical Practice

  • None cited

Transferable Evidence from Other Procedures

  • Three studies in major thoracic or abdominal surgery showed that addition of epinephrine 1.5–2 µg/ml to thoracic epidural local anaesthetic plus strong opioid reduced pain intensity Niemi et al 1998 Click here for more information
  • Epinephrine 1.5–2 µg/ml was associated with reduced frequency of pruritis (p<0.002; n=36) Niemi et al 2003

Thoracotomy-specific Evidence

  • Addition of epinephrine to thoracic epidural strong opioid was superior to epidural strong opioid alone for reducing use of epidural fentanyl, and for extending the duration of analgesia Baron et al 1996 Click here for more information
  • Postoperative epidural methylprednisolone did not significantly reduce pain scores at rest and on mobilisation, or total morphine requirement over 48 h, compared with placebo (n=24) Blanloeil et al 2001
  • Postoperative epidural methylprednisolone did not significantly reduce the incidence of PONV compared with placebo (n=24) Blanloeil et al 2001
  • Addition of epinephrine to postoperative thoracic epidural strong opioid did not significantly reduce pain scores compared with epidural strong opioid alone Baron et al 1996 Click here for more information
  • Addition of epinephrine to postoperative thoracic epidural strong opioid did not significantly reduce the incidence of PONV compared with epidural strong opioid alone (n=34; n=23) Baron et al 1996
  • Addition of epinephrine to postoperative thoracic epidural strong opioid was associated with similar pulmonary function to epidural strong opioid alone: FEV1, FVC (n=34) PaCO2(n=23) Baron et al 1996
  • Study details Blanloeil et al 2001 Click here for more information

Analgesic Peripheral Nerve Blocks

PROSPECT Recommendations

  • Paravertebral block with LA is recommended as an alternative to thoracic epidural LA plus strong opioid, based on evidence that the technique provides comparable postoperative analgesia and may be associated with fewer adverse effects (Grade A; see also Postoperative Paravertebral Block)

Clinical Practice

  • A paravertebral block can be used in combination with other analgesic techniques, as part of a multimodal analgesic regimen
  • Paravertebral LA may be administered as a bolus at the end of surgery
  • Paravertebral block is used less frequently than epidural analgesia in clinical practice

Transferable Evidence

  • Paravertebral block improved pain relief, reduced opioid use and was associated with improved pulmonary function compared with placebo in pleurectomy Mozell et al 1991
  • Four studies in breast surgery found that paravertebral block was associated with analgesic benefits compared with control Kairaluoma et al 2004 Click here for more information
  • Bilateral paravertebral block combined with general anaesthesia reduced pain scores, supplementary analgesic use, and the incidence of PONV, compared with general anaesthesia alone in laparoscopic cholecystectomy (n=60) Naja et al 2004

Thoracotomy-specific Evidence

  • Most studies of paravertebral block included postoperative administration, with or without an additional pre- or intra-operative bolus; all studies (with the exception of Richardson et al 1994

PROSPECT Recommendations

  • Intercostal nerve block with LA via a catheter is recommended, if epidural analgesia and paravertebral block are not possible (Grade D), based on evidence for a reduction in pain compared with systemic analgesia (Grade A) (see also Postoperative Intercostal Nerve Block)

Clinical Practice

  • Infusion techniques for intercostal nerve blocks are more convenient for use in clinical practice and adequate analgesia is more likely to be maintained than with intermittent bolus administration

Transferable Evidence

  • Two studies in open cholecystectomy and one study in upper abdominal surgery showed that intercostal nerve block did not significantly reduce pain scores compared with control (n=37, n=40, n=66) Maidatsi et al 1998
  • In open cholecystectomy, intercostal nerve block reduced supplementary opioid use compared with control in one study (n=37) Maidatsi et al 1998
  • A meta-analysis found that intercostal nerve block tended to reduce the incidence of pulmonary complications, but these differences did not achieve statistical significance. There were no significant differences in surrogate measures of pulmonary function (FEV1, FVC, and PEFR) Ballantyne et al 1998
  • The incidence of pneumothorax following intercostal nerve block in thoracic and upper abdominal surgery has been reported in the range of 0.073% to 19% Shanti et al 2001

Thoracotomy-specific Evidence

PROSPECT Recommendations

  • Addition of dextran to LA solution is not recommended because of lack of analgesic benefit (Grade A)
  • Intercostal phenol is not recommended because of limited evidence and the potential risk of neuropathic pain (Grade D)

Clinical Practice

  • Phenol may induce neuropathic pain

Transferable Evidence

  • None cited

Thoracotomy-specific Evidence

  • Intercostal bupivacaine plus dextran was superior to bupivacaine alone for extending the duration of skin anaesthesia as determined by pinprick (p<0.005) (n=12) Kaplan et al 1975
  • Intercostal nerve block with phenol reduced pain scores compared with control (no statistical analyses) (n=73) Roviaro et al 1986
  • Intercostal bupivacaine plus dextran was similar to bupivacaine alone for pain scores on days 1, 2 and 3 (n=12) Kaplan et al 1975
  • Intercostal bupivacaine plus dextran was similar to bupivacaine alone for the use of supplementary morphine on days 1, 2 and 3 (n=12) Kaplan et al 1975
  • Intercostal bupivacaine plus dextran was associated with similar pulmonary function to bupivacaine alone (FVC, FEFR, PaCO2, PaO2) (n=12) Kaplan et al 1975
  • Intercostal phenol was associated with similar pulmonary function to control in patients undergoing lobectomy, but was associated with superior pulmonary function in patients undergoing pneumonectomy Roviaro et al 1986 Click here for more information
  • Study details Kaplan et al 1975 Click here for more information

PROSPECT Recommendations

  • Interpleural strong opioid is not recommended due to limited evidence (Grade D)

Clinical Practice

  • None cited

Transferable Evidence

  • None cited

Thoracotomy-specific Evidence

Cryoanalgesia

PROSPECT Recommendations

  • Cryoanalgesia is not recommended due to the risk of neuropathic pain (Grade A), and inconsistent results for analgesia compared with control (Grade A)

Clinical Practice

  • Cryoanalgesia may increase the incidence of chronic pain and neuralgia

Transferable Evidence

  • Cryoanalgesia was of no benefit for reducing VAS pain scores compared with no treatment or sham treatment in two studies in herniorraphy (n=36) Khiroya et al 1986

Thoracotomy-specific Evidence

  • Cryoanalgesia was similar to postoperative indomethacin for pain scores at rest and on movement on days 1 and 2, and supplementary papaveretum use during 0–24 h (n=60) Keenan et al 1983
  • Cryoanalgesia plus intravenous morphine was associated with similar pulmonary function (FVC and FEV1) compared with postoperative interpleural bupivacaine (n=24) Miguel et al 1993
  • Cryoanalgesia was superior to postoperative interpleural LA for reducing the proportion of patients requiring supplementary papaveretum (no p-value) but not the dose of papaveretum or requirement for oral analgesia (n=31) Shafei et al 1990
  • Cryoanalgesia plus intravenous morphine was similar to postoperative interpleural bupivacaine for use of supplementary morphine (n=24) Miguel et al 1993
  • In two of three studies, intra-operative cryoanalgesia was superior to intercostal bupivacaine for reducing supplementary analgesic requirements Orr et al 1981 Click here for more information
  • Cryoanalgesia plus intravenous morphine was superior to postoperative interpleural bupivacaine for reducing pain scores on day 1 (p<0.05) but not on days 2 or 5, and for reducing persistent postthoracotomy pain at 12 weeks (p<0.007) (n=24) Miguel et al 1993
  • Cryoanalgesia was similar to postoperative interpleural LA for pain scores (n=31) Shafei et al 1990
  • Cryoanalgesia was similar to intra-operative intercostal bupivacaine plus postoperative intravenous morphine infusion for pain scores at rest, on movement or on physiotherapy on days 0, 1 or 8, and for supplementary morphine use (n=30) Orr et al 1981
  • In two of three studies, cryoanalgesia was superior to intercostal bupivacaine for reducing pain scores Orr et al 1981 Click here for more information
  • Cryoanalgesia plus intravenous morphine was associated with similar pulmonary function (FVC and FEV1) compared with lumbar epidural morphine (n=24) Miguel et al 1993
  • Cryoanalgesia plus intravenous morphine was superior to lumbar epidural analgesia for reducing the proportion of patients with persistent postthoracotomy pain at 12 weeks (p<0.007) (n=24) Miguel et al 1993
  • Cryoanalgesia was associated with superior PF values on days 1 and 2 (p<0.001) compared with postoperative indomethacin (n=60) Keenan et al 1983
  • In four of seven studies, cryoanalgesia was similar to control for reducing pain scores Brichon et al 1994 Click here for more information
  • In four of seven studies, cryoanalgesia was similar to control for reducing supplementary analgesic requirements Keenan et al 1983 Click here for more information
  • Cryoanalgesia was associated with more frequent long-term pain or neuralgia compared with control Muller et al 1989 Click here for more information
  • Cryoanalgesia was associated with similar pulmonary function compared with control Brichon et al 1994 Click here for more information
  • Cryoanalgesia was inferior to thoracic epidural analgesia for reducing pain scores: on days 1 and 2 (p<0.05) but not days 3–6 (n=87) Brichon et al 1994
  • Cryoanalgesia was inferior to postoperative thoracic epidural infusion of bupivacaine plus fentanyl for reducing supplementary oral analgesic use on days 1–6 (p<0.05) and intravenous analgesic use on days 0 and 1 (p<0.05) (n=87) Gough et al 1988 Click here for more information
  • One of two studies showed that cryoanalgesia was associated with inferior pulmonary function (FVC, but not FEV1) on day 7 (p<0.05) compared with thoracic epidural infusion of bupivacaine plus fentanyl (n=87) Gough et al 1988 Click here for more information
  • Cryoanalgesia plus intravenous morphine was inferior to lumbar epidural morphine for reducing pain scores on day 0 (p<0.05) but not on days 2 or 5 (n=24) Miguel et al 1993
  • Study details Brichon et al 1994 Click here for more information

Analgesia For Shoulder Pain

PROSPECT Recommendations

  • Phrenic nerve block is not recommended to prevent post-thoracotomy shoulder pain due to limited evidence and the risk of impaired pulmonary function (Grade D)

Clinical Practice

  • Phrenic nerve block may interfere with diaphragmatic function and is associated with impaired respiratory function

Transferable Evidence

  • None cited

Thoracotomy-specific Evidence

  • Intra-operative phrenic nerve infiltration with lidocaine was superior to placebo for reducing the proportion of patients with shoulder pain immediately after surgery (p<0.008), total VAS pain scores during 0–2 h (p<0.05) and VRS scores at 30 min (p=0.0028), 1 h (p=0.016), and 2 h (p=0.0018), but not at 3–6 h (n=42) Scawn et al 2001
  • One study showed that intra-operative phrenic nerve infiltration with lidocaine was not significantly different from placebo for the amount of epidural solution used (n=42) Scawn et al 2001
  • Intra-operative phrenic nerve infiltration with lidocaine was associated with similar PaCO2 to placebo (n=42) Scawn et al 2001
  • Study details Scawn et al 2001 Click here for more information

Operative Techniques

PROSPECT Recommendations

  • Muscle-sparing thoracotomy reduced postoperative pain compared with conventional technique
  • Anterior thoracotomy may reduce postoperative pain compared with posterolateral thoracotomy
  • Intracostal sutures may reduce postoperative pain compared with pericostal sutures
  • Intercostal muscle flap may reduce postoperative pain compared with conventional technique
  • However, the operative technique used should also depend on factors other than postoperative pain (Grade D)

Clinical Practice

  • The recommendations apply to open thoracotomy, not video-assisted thoracotomy

Transferable Evidence

  • None cited

Thoracotomy-specific Evidence

  • Video-assisted thoracic surgery was superior to conventional axillary thoracotomy for reducing pain scores at 3 h (p<0.05), 15 h (p<0.01), 24 h (p<0.05), 48 h (p<0.01) and 72 h (p<0.01) (n=47) Tschernko et al 1996
  • Video-assisted thoracic surgery was superior to conventional axillary thoracotomy for reducing piritramide requirements at 3 h (p<0.01), 15 h (p<0.05), 24 h (p<0.01), 48 h (p<0.01) and 72 h (p<0.01) (n=47) Tschernko et al 1996
  • Video-assisted thoracic surgery was associated with increased PaO2 at 3, 15, 24, 48 and 72 h (p<0.05) compared with conventional axillary thoracotomy, but PaCO2 was not significantly different between groups (n=47) Tschernko et al 1996
  • Video-assisted thoracoscopy was superior to muscle-sparing lateral thoracotomy for reducing pain scores at day 6 (p<0.05), and for reducing ketorolac use (p<0.05) (n=44) Santambrogio et al 1995
  • Video-assisted thoracoscopy was superior to muscle-sparing lateral thoracotomy for reducing the duration of hospital stay (p<0.01) (n=44) Santambrogio et al 1995
  • In three of four studies, muscle-sparing thoracotomy was superior to standard posterolateral thoracotomy for reducing pain scores Akcali et al 2003 Click here for more information
  • In three of four studies, muscle-sparing thoracotomy was superior to standard posterolateral thoracotomy for reducing supplementary analgesic requirements Akcali et al 2003 Click here for more information
  • Intercostal muscle flap reduced pain scores on days 1–2 and at weeks 1–4, 8 and 12 (p<0.05), reduced analgesic requirements (p<0.05), and was associated with a smaller decrease in spirometric values (p<0.05), compared with control (n=114) Cerfolio et al 2005
  • A retrospective analysis found that non-serratus-sparing antero-axillary thoracotomy reduced chest pain on day 1 and from day 14 to 6 months after surgery (p<0.01 to p<0.001), compared with posterolateral thoracotomy; postoperative mortality, morbidity, and hospital stay were similar between groups (n=50) Nomori et al 1997
  • A cohort study found that intracostal sutures (stitches placed on top of the fifth and seventh ribs) for chest closure were less painful than pericostal sutures (stitches placed on top of the fifth rib and through small holes drilled in the bed of the sixth rib) at 2 weeks and 1–3 months after thoracotomy (n=280) Cerfolio et al 2003b
  • Video-assisted thoracoscopy and limited anterolateral thoracotomy were similar for pain scores during 1–72 h, at 2 weeks, 4 weeks and at 3 months, and for morphine use (n=42) Miller et al 2000
  • Video-assisted thoracoscopy and limited anterolateral thoracotomy were similar for the duration of hospital stay (n=42) (Miller 2000)
  • Video-assisted thoracoscopy and limited anterolateral thoracotomy were associated with similar pulmonary function (FEV1) on days 1, 2, 14 and 28 (n=42) Miller et al 2000
  • Three studies showed that muscle-sparing thoracotomy was similar to standard posterolateral thoracotomy for the duration of hospital stay (n=60; n=50; n=30) Akcali et al 2003
  • In three of four studies, muscle-sparing thoracotomy was similar to standard posterolateral thoracotomy for pulmonary function parameters Akcali et al 2003 Click here for more information
  • Study details Tschernko et al 1996 Click here for more information