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Ann Thorac Surg 1999;67:1643-1647
© 1999 The Society of Thoracic Surgeons
a Klinik für Herzchirurgie, Herzzentrum, Universität Leipzig, Leipzig, Germany
Accepted for publication December 14, 1998.
Address reprint requests to Dr Walther, Klinik für Herzchirurgie, Universität Leipzig, Herzzentrum, Russenstrasse 19, 04289 Leipzig, Germany
e-mail: walt{at}server3.medizin.uni-leipzig.de
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Abstract |
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 Top Abstract IntroductionMaterial and methodsResultsCommentReferences |
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Methods. From October 1996 to May 1997 a total of 338 patients were interviewed daily using standard scoring systems (myocardial revascularization, n = 160; mitral valve reconstruction or replacement, n = 58; aortic valve replacement, n = 120).
Results. Regarding ventricular function and intensive care and hospital stay, there were no significant differences between groups. Pain decreased until the seventh postoperative day in all patients. Patients with a lateral minithoracotomy (minimally invasive revascularization and mitral valve operations) had lower pain levels from the third postoperative day onward. There were no differences in quality of life, postoperative wound healing, or stability of the bony thorax.
Conclusions. In cardiac operations overall pain levels are relatively low. After minimally invasive procedures with lateral minithoracotomy, earlier mobilization is possible because of a better stability of the bony thorax, resulting in lower pain levels.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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In general, postsurgical pain is transient. Maximal pain levels can be anticipated to occur immediately postoperatively until the third postoperative day. As surgical wound healing progresses, pain levels usually decrease. Few studies have focused on the postoperative pain and QOL in cardiac operations. The studies performed have demonstrated an improvement in postoperative QOL for patients both after coronary artery bypass graft and heart valve operations [1–4]. With the introduction of minimally invasive techniques in cardiac surgery (MIS), there has been renewed interest in evaluating all related aspects. Different minimally invasive operations have been developed: single- or two-vessel revascularization of the left anterior descending or the diagonal coronary artery branches using the off-pump beating heart technique; mitral valve repair or replacement using femoral perfusion and a right lateral minithoracotomy; and aortic valve replacement using different types of partial sternotomies.
The term minimally invasive implies that patients have less discomfort and less impairment of their daily activities. This hypothesis has not been further tested so far. Therefore this study was performed to prospectively analyze whether there are any differences in postoperative pain or QOL after MIS in comparison with conventional cardiac operations. Different scoring systems were used to evaluate these criteria.
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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All conventional operations consisted of a standard median sternotomy, thoracic access for the heart-lung machine, and cold crystalloid cardioplegia. Minimally invasive operations were performed differently: MIS bypass patients underwent a left lateral minithoracotomy in the fifth intercostal space and were operated on using the beating heart technique; MIS mitral valve operations were performed using a right anterolateral minithoracotomy in the fifth intercostal space, and extracorporeal circulation was established by means of the right femoral vessels using an endoaortic clamp; and MIS aortic valve replacement was performed using a partial sternotomy and direct thoracic cannulation.
All patients were interviewed on a daily basis up to the seventh day postoperatively using a standard pain questionnaire shown in Figure 1. The pain questionnaire included data about pain intensity, character, change in pain intensity over time, localization, occurrence of pain in relation to physical activities, dosage of pain medication as well as effectivity. Furthermore, patients were asked whether they could breathe, move, and perform all other activities without any discomfort. Pain intensity was analyzed using the verbal rating scale and the visual analog scale. The verbal rating scale has a five-step approach and allows differentiation between no pain, mild, moderate, severe, and unbearable pain. Furthermore, the visual analog scale was used to quantify pain from 1, which is no pain, up to 10, which is the worst pain the patient has ever had. Postoperative pain assessment was performed on a daily basis for 7 days by direct interview.
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Preoperative patient characteristics are shown in Table 1. Overall, 67% of the patients were men, and 38% of all patients had an MIS approach. Patients operated on with an MIS technique were statistically significantly younger (60.5 ± 10.8 versus 63.5 ± 10.2 years), whereas there were no differences between the groups for body surface area and left ventricular function.
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Results |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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When asked about postoperative pain medication, all patients stated that it was sufficient. Furthermore if any severe pain was mentioned, the interviewer reminded the patient that pain medication was available at all times on request. Postoperatively most patients were transferred for 3 to 4 weeks to a rehabilitation center according to the German standards. Therefore telephone interview follow-up was performed at 3 months postoperatively. Follow-up was complete in 95% of patients, most of whom had returned to their routine preoperative activities.
Between the MIS and the Conv approach there were no significant differences in terms of preoperative cardiovascular risk factors, the amount of pain medication on the intensive care unit as well as on the regular ward, the duration of mechanical ventilation, and requirements for blood transfusion. The chest tubes for wound drainage were in place for an average of 39 and up to 55 hours, with no difference between groups.
Duration of intensive care and total hospital stay is shown in Table 2. Average intensive care stay was approximately 1 day after MIS operations whereas it was almost 2 days in the Conv groups. There was no difference in the duration of total hospital stay for all patients in the bypass groups, whereas patients having an MIS valve procedure were discharged earlier.
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Pain intensities according to the verbal rating scale for postoperative day 2 in comparison with postoperative day 7 are given in Figure 2. Early postoperative pain levels were relatively higher as reflected by more patients expressing moderate, severe, or even unbearable pain. Before discharge pain levels had decreased in almost all cases. The majority of patients had no or only mild pain before discharge.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Pain perception is individual rather than standardized. Thus postoperative pain and QOL are not easy to assess, and reliable data are difficult to collect. The results may depend on many factors, including socio-economic status and differences in race and sex. With the use of scoring systems these data can be partially quantified [5, 6]. The pain questionnaire included some standard instruments for pain assessment; in addition, several aspects relevant for patients after cardiac operations were asked. Only when using such scores and daily interviews is it possible to collect data that reveal the exact health status of the patients. Some conclusions can be drawn but in the end individual aspects remain.
One of the most important results of this study was finding that overall pain levels after cardiac operations are relatively low in most patients. As such postoperative pain is bearable, and the patients receive sufficient pain medication on request. As anticipated, thoracic pain is of tolerable intensities if the sternum and the ribs are stable postoperatively. When looking at the relation of pain to the patients’ activities, this study confirms prior findings: all patients suffered most during mobilization and coughing. This can be directly related to the thoracic incision and friction of the split sternum during these maneuvers.
It is very difficult to continuously assess pain throughout a whole day or week. Usually pain perception is situational, and patients have difficulties remembering how the pain was before they received any medication. In this study patients knew that the interviewer would pass by every afternoon and were asked to summarize their pain perception for the whole day. Therefore the results presented are reliable.
One result was that pain levels decreased progressively during the first 7 days postoperatively. Differences in postoperative pain medication were not observed. Nevertheless patients having a lateral minithoracotomy suffered more pain during the first 2 postoperative days. As a consequence we now routinely apply an intercostal catheter to be able to inject local anesthetics. The other option would be to use a peridural catheter preoperatively. We consider this technique too invasive in terms of the risk of perioperative bleeding after anticoagulation therapy. From the third postoperative day onward, patients who underwent minimally invasive lateral thoracotomy (MIS bypass and mitral valve operations) suffered less pain, a finding that was close to reaching statistical significance. This is an important finding that may be explained by the fact that mobilization of patients with a lateral minithoracotomy is rather painless as compared with median sternotomy, in which strain caused by mobilization causes bony friction. Nevertheless no such advantage was observed after MIS aortic valve operations. This might be related to the fact that a partial sternotomy was performed and that intraoperative spreading of the sternum might cause some postoperative discomfort. Maybe the result was also caused by the small numbers of patients, who were not randomly assigned for ethical reasons. There was an improvement in postoperative QOL for all patients, which is in agreement with results from the literature [1, 6, 7]. A modified standard scoring system was used; nevertheless the individual’s QOL is hard to quantify. Therefore the evaluation was done as a dimensionless score, and the preoperative score served as a baseline. For the MIS in comparison with the Conv approach there were no relevant differences in postoperative QOL at 3 months. There may be some differences during the first and second postoperative month. With the current German standard of postoperative cardiac rehabilitation, relevant data would be hard to obtain. Therefore data from patients who are discharged to home and participate in filling in a weekly questionnaire would be helpful for further studies. There might be a psychological aspect of the MIS approach because patients anticipate less pain from a small incision this might motivate them for early mobilization resulting in earlier recovery.
In conclusion few relevant differences were seen between the MIS and the Conv approaches. From the third postoperative day onward patients having a lateral minithoracotomy perceived less pain. To further prove the benefits of a lateral minithoracotomy in terms of pain reduction an even larger series might be necessary.
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