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Ann Thorac Surg 1998;65:803-806
© 1998 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

One-Day Admission for Lung Lobectomy: An Incidental Result of a Clinical Pathway

Department of Cardiothoracic Surgery, St Jude Medical Center, Fullerton, California, USA
Department of Pulmonary Medicine, St Jude Medical Center, Fullerton, California, USA
Department of Oncology, St Jude Medical Center, Fullerton, California, USA
Department of Cardiothoracic Surgery, University of California, Irvine Medical Center, Orange, California, USA

Accepted for publication September 9, 1997.

Dr Tovar, 100 E Valencia Mesa Dr, Suite 301, Fullerton, CA 92835 (e-mail: etovarmd@aol.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Addendum Acknowledgments References

 
Background. Most complications after lung lobectomy are related to pain, narcotic analgesia, and inactivity. When the operation is performed with the goal of minimizing postoperative pain, and when rapid restoration of activity and patient independence can be achieved, most postoperative complications can be obviated and early discharge can be attained.

Methods. Since March 1996, we have performed 10 consecutive elective major lung resections (8 lobectomies and 2 bilobectomies) for neoplastic (n = 8) and benign inflammatory (n = 2) lesions. Of the 10 patients, 4 were men and 6 were women ranging in age from 58 to 77 years (mean age, 66 years). Extensive preoperative patient and family education was provided in the surgeon’s office. Same-day admission was followed by an oblique muscle-sparing minithoracotomy to access the chest cavity. A meticulous operation, with special attention to minimizing air leak and postoperative discomfort, was performed. Intercostal nerve cryolysis was used as the main method of analgesia.

Results. All patients underwent the planned operation through a minithoracotomy and were extubated in the operating room. All patients exhibited normal ipsilateral shoulder girdle mobility in the recovery room and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation. The chest tube was removed the night of the operation in 2 patients, the morning after the operation in 6 patients, and on the second postoperative day in 1 patient. One patient who was discharged with a Heimlich valve had this device removed in the office 4 days after the operation. After the chest tubes were removed, there were no instances of pneumothorax. All 10 patients were able to ambulate independently on the first postoperative day. Eight patients were discharged home the morning after the operation and 2 on the second postoperative day. None of the patients have required readmission related to their operation or have exhibited evidence of postthoracotomy pain syndrome.

Conclusions. We have developed a clinical pathway based on patient education, meticulous minimally invasive operation, cryoanalgesia, and quick resumption of physical activity. Our preliminary experience with this approach has shown minimal morbidity, rapid restoration to preoperative status, and, for most patients, a 1-day hospital stay after major lung resection.

	Introduction

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Incisional pain after a thoracotomy causes poor lung expansion, atelectasis, prostration, and, occasionally, pneumonia and respiratory failure [1][2][3]. Traditionally, postthoracotomy pain is managed with intramuscular or intravenous narcotics [4]. Opioid agents, however, possess a narrow therapeutic window. Their adverse effects include somnolence, inactivity, nausea, respiratory depression, and some degree of hypotension that may require fluid administration [5]. The hospital environment exposes patients to continuous activity around the clock, which causes sleep deprivation and intense fatigue. The patients, who have just lost part of the functioning lung, are facing the possibility of a shorter life expectancy and now have to worry whether adjuvant therapy will be needed after surgical resection. In addition, these patients usually are chronic smokers who suddenly have to discontinue this addictive habit. The mental and physical stress associated with severe incisional pain, poor lung expansion, prostration, and poor appetite and food intake set the stage for complications in patients who have undergone major lung resection. In an attempt to minimize these complications, we created a clinical pathway that we have used in 10 patients in whom we have performed major lung resection.

	Patients and Methods

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Since March 1996, 10 consecutive patients have been referred to our service for major lung resection with confirmed or presumed stage I (T1 N0, T2 N0) non–small cell carcinoma of the lung. There were 4 men and 6 women ranging in age from 58 to 77 years (mean age, 66 years). All the patients had a significant smoking history (range, 20 to 110 pack-years; mean, 61.5 pack-years). Eight patients had bronchogenic carcinoma and 2 had benign inflammatory lesions (Table 1). The two benign lesions were large, centrally located, and near the hilum. Computed tomographic scanning of the chest and upper abdomen, spot pulse oximetry, and pulmonary function testing were obtained as part of the initial evaluation. A hemogram, chemistry panel, prothrombin time, activated partial thromboplastin time, urinalysis, and electrocardiogram were performed in preparation for a same-day admission operation.

All the patients were operated on by one of the authors. A subclavian vein triple-lumen catheter was inserted in every patient on the side of the operation. The use of an arterial line was left to the discretion of the anesthesiologist for intraoperative monitoring but was discontinued in the recovery room. Using a double-lumen endotracheal tube, anesthesia was provided by six different anesthesiologists using routine techniques (premedication with midazolam, induction with propofol, and maintenance with nitrous oxide, sevoflurane, and narcotics). The chest cavity was accessed through an oblique muscle-sparing minithoracotomy similar in size to the utility thoracotomy used for video-assisted thoracic surgery lobectomy. This minithoracotomy approach (Fig 1) consists of a 6- to 8-cm incision made over, and parallel to, the intercostal space to be entered. This incision is placed anterior to the latissimus muscle and the serratus muscle, separated between its digitations. A pediatric chest retractor is used and the ribs are retracted no more than 5 cm.

View larger version (128K): [in this window] [in a new window]   A 77-year-old patient 10 days after left upper lobectomy. Notice the full shoulder girdle mobility.

Patients were extubated in the operating room and transferred to the recovery room, where they were observed closely. Foley catheters and peripheral lines were removed before the patients were discharged from the recovery room and transferred to an intermediate care unit. There, all patients were helped out of bed, incentive spirometry was started, a diet was begun and intake increased as tolerated, intravenous fluids were discontinued, and oxygen was weaned off using continuous pulse oximetry. Because intravenous narcotics were not necessary, none were given. During the night, vital signs and other interventions were kept at a minimum depending on the individual condition of each patient. Postoperative blood tests were ordered only for specific reasons. A portable chest roentgenogram was performed in the recovery room and every morning during the patient’s hospital stay. Patients were allowed to ambulate on the first postoperative day and, when they were independent and had no air leak present, were discharged home.

	Results

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All patients were extubated in the operating room. One patient had to be reintubated in the recovery room because of incomplete reversal of the muscle relaxant. Thirty minutes later, he was extubated and had a subsequently normal postoperative course. All patients exhibited normal ipsilateral shoulder girdle mobility immediately after operation. Air leaks subsided early and allowed removal of the chest tube on the night of operation in 2 patients, the first postoperative day in 6 patients, and the second postoperative day in 1 patient. The single patient who was discharged home with a Heimlich valve in place had the device removed in the office 4 days after operation (Table 2). The amount of chest tube drainage was not considered to be a criterion for determining the timing of chest tube removal unless the fluid was frankly hemorrhagic. There were no instances of pneumothorax after chest tube removal or subsequent pleural effusions. All patients were ambulating on the first postoperative day. Chest roentgenograms and laboratory tests were performed judiciously. A total of 5 hemograms, 7 blood chemistries, 5 arterial blood gases, and 23 chest roentgenograms were performed for all 10 patients during their entire hospital stay (Table 3). Eight patients were discharged home on the first postoperative day and 2 on the second day, for a total of 12 hospital days for all 10 patients (Table 2). None of the patients has required readmission related to their operation or has exhibited evidence of postthoracotomy pain syndrome. Most of the patients resumed normal activities approximately 10 days after the operation.

	Comment

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Cryoanalgesia first was introduced by Nelson and colleagues in 1974 [8]. The technique has both advocates [9][10][11] and opponents [12][13][14]. Without a definitive study, however, it remains controversial. We have used intercostal nerve cryolysis selectively since 1987 and routinely since 1993 as the main method of postthoracotomy analgesia. Because there are so many technical variables (ie, whether the nerves should be dissected before cryolysis, the number of levels that should be treated, whether the probe should be applied proximal or distal to the collateral branch, the optimal freezing time, the best freeze-thaw-freeze sequence to use, the ideal cryoprobe), satisfactory resolution of this controversy seems unlikely. It also is possible that some of the postthoracotomy neuralgias blamed on cryoanalgesia by some opponents of this technique may be the result of entrapped intercostal nerves by misplaced pericostal sutures, rather than a complication of cryolysis.

Perioperative management in this group of patients demands compulsive attention to detail. The surgeon constantly has to make educated decisions that cannot be delegated. For instance, the decision to remove the chest tube early, which is important because its presence provokes irritation (in some patients more than others) unrelieved by cryoanalgesia or other local therapy, is made on the basis of the degree of air leak that was present in the operating room with the lung submerged under water, the amount of lung emphysema that was observed in the preoperative computed tomogram, and the presence of a complete anatomic fissure, among other factors, in addition to the obvious absence of air leak and space problems. Finally, education of the patient, the family, and the health care workers is fundamental to any successful clinical pathway.

In conclusion, we have identified pain, narcotic analgesia, inactivity, and the negative effects of being a hospital inpatient as eventual sources of major complications after lung resection. As a result, we have created a clinical pathway to minimize these risk factors. Preliminary experience seems to indicate that this clinical pathway results in minimal morbidity, rapid restoration to the preoperative status, and, as by-products, reduced costs and shortened hospital stays.

	Addendum

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Since the submission of this article, we have performed 19 additional consecutive major lung resections (5 pneumonectomies, 3 bilobectomies, 9 lobectomies, 1 lobectomy with a chest wall resection, and 1 lobectomy with resection of the diaphragm). All 19 patients had malignant lesions. Patients ranged in age from 43 to 87 years (mean age, 65 years). One patient was discharged the day of the operation (pneumonectomy), 14 were discharged on the first postoperative day (4 pneumonectomies, 3 bilobectomies, 5 lobectomies, and 2 extended lobectomies), 2 were discharged on the second, 1 on the third, and 1 on the fourth postoperative day (lobectomies).

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Addendum Acknowledgments References

 
We gratefully acknowledge Jean L. Burnette for her invaluable editorial assistance in the preparation of the manuscript and Carol Bondurant, St. Jude Medical Center Library, for compilation of the material.

	References

Top Abstract Introduction Patients and Methods Results Comment Addendum Acknowledgments References

 

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