preventing post operative complications

Post operative pain after thoracic surgery

What kind of pain should patients expect after thoracic surgery, and how long will it last? Also, is this normal? When should I call my doctor?

Like all posts here at Cirugia de Torax, this should serve as a guide for talking to your healthcare provider, and is not a substitute for medical advice.

Quite a few people have written in with questions about post-operative pain after thoracic surgery procedures so we will try to address those questions here.

1. What is a normal amount of pain after these procedures?

While no two people will experience pain the same, there are some general guidelines to consider. But to talk about this issue – we will need to refer to a basic pain scale which rates pain from 0 (no pain) to 10 – (excruciating, writhing pain, worst possible imaginable).

Unfortunately, for the majority of people who have thoracic surgery, there will be some pain and discomfort.

Pain depends on the procedure

In general, the intensity and duration of pain after thoracic procedures is related to the surgical approach – or the type of surgical incision used.

open thoracotomy,empyema, advanced with extensive purulence — This open incision (with rib spreading) will hurt more..
Photo: advanced empyema requiring open thoracotomy for decortication

Pain will be much less with a single incision VATS surgery (now with chest tube) and specimen removed (photo courtesy of Dr. Chen)

Patients with larger incisions like a sternotomy, thoracotomy or clamshell incision will have more pain, for a longer period of time than patients that have minimally invasive procedures like VATS because there is more trauma to the surrounding tissues. People with larger incisions (from ‘open surgeries’) are also more likely to develop neuralgia symptoms as they recover.

. (I will post pictures of the various incisions once I return home to my collection of surgical images).

Many patients will require narcotics or strong analgesics for the first few days but most surgeons will try to transition patients to anti-inflammatories after surgery.

Post-operative surgical pain is often related to inflammation and surgical manipulation of the chest wall, particularly in procedures such as pleurodesis, decortication or pleurectomy. For many patients this pain will diminish gradually over time – but lasts about 4 to 6 weeks.

Anti-inflammatories

This pain is often better managed with over the counter medications such as ibuprofen than with stronger narcotics. That’s because the medication helps to relieve the inflammation in addition to relieving pain. Anti-inflammatory medications also avoid the risks of oversedation, drowsiness and severe constipation that often comes with narcotics.

Use with caution

However, even though these medications are available without a prescription be sure to talk to your local pharmacist about dosing because these medications can damage the kidneys. Also, be sure to keep hydrated while taking this medications.

People with high blood pressure should be particularly cautious when taking over the counter anti-inflammatories because many of these medications have drug interactions with blood pressure medications.

2. “I had surgery three weeks ago, and I recently developed a burning sensation near the incision”

Neuralgias after surgery

For many patients, the development of a neuralgia is a temporary effect and is part of the healing process. However, it can be quite disturbing if patients are unprepared. Neuralgic pain is often described as a burning or stinging sensation that extends across the chest wall from the initial incision area. Patients also describe it as a ‘pins and needles’ sensation or “like when your foot falls asleep”. This usually develops a few weeks after surgery as the nerves heal from the surgery itself.

It the discomfort is unmanageable, or persists beyond a few weeks, a return visit to your surgeon is warranted. He/She can prescribe medications like gabapentin which will soothe the irritated nerves and lessen the sensations. However, these medications may take some time to reach full effect.

Range of motion and exercise after surgery

Exercise limitations are related to the type of incision.

Sternotomy incisions/ sternotomy precautions

If you have a sternotomy incision – (an incision through the breast bone at the center of your chest), this incision requires strict precautions to prevent re-injury to the area. Since the sternal bone was cut, patients are usually restricted from lifting anything greater than 10 pounds for 6 to 12 weeks, and to avoid pushing, pulling or placing stress on the incision. Patients are also restricted from driving until bone healing is well underway. (Be sure to attend a rehab program or physical therapy program to learn the proper way to exercise during this time period).

Patients will also need to take care to prevent a surgical skin infection or something more serious like mediastinitis. The includes prohibitions against tub bathing/ soaking, swimming or over- aggressive cleaning of the incision with harsh abrasives like hydrogen peroxide or anti-bacterial soaps. These chemicals actually do more harm than good in most cases by destroying the newly healing tissue. A good rule of thumb to remember (unless your doctor says otherwise): No creams or lotions to your incisions until the scabs fall off.

Post-thoracotomy incisions

With a large thoracotomy incision, most patients will be restricted from lifting any items greater than 10 pounds on the surgery side for around two weeks. However, unlike sternotomy patients – we want you to use and exercise that arm daily – otherwise patients have a risk of developing a ‘disuse’ syndrome. One of the common exercises after a thoracotomy is called the spider crawl. This exercise helps the muscles to heal and prevent long-term disability or problems. The physiotherapist at your local hospital should have a list of several others that they can teach you to practice at home.

The spider crawl

In this example, the patient had a left thoracotomy:

1. Stand with your surgical side within arm’s length of the wall.

Now, use your hand to “walk” up the wall, similar to a spider crawling.

'walking' the hand up the wall — ‘walking’ the hand up the wall

Continue to walk your hand up the wall until your arm is fully extended.

Perform this exercise (or similar ones) for several minutes 5-6 times a day. As you can see – it is fast and easy to do.

VATS

For patients with minimally invasive procedures – there are very few exercise restrictions, except no heavy lifting for 2 to 3 weeks (this is not the time to help your neighbor move his television.)

General incision care guidelines are similar to that for sternotomy patients – no soaking or bathing (showering is usually okay), no creams or lotions and no anti-bacterial soaps/ hydrogen peroxide/ harsh cleaners.

Whats NOT normal – when it’s time to call your surgeon

– dramatic increase in pain not associated with activity (i.e. lifting or reaching). If your pain has been a “4” for several days and suddenly increases to an “8”

– If the quality of the pain changes – ie. if it was a dull ache and becomes a stabbing pain.

– any breathlessness, shortness of breath or difficulty breathing

– Any increase in redness, or swelling around your incisions. Incisions may be pink and swollen for the first 2-3 days, but any increase after that warrants a ‘wound check’ by your surgeon

– Any fresh bleeding – bright red blood. A small amount of drainage (from chest tube sites) that is light pink, clear or yellow in nature may be normal for the first few days.

– Drainage from the other sites (not chest tube sites) such as your primary incision is not normal and may be a sign of a developing infection.

– Fever, particularly fever greater than 101.5 – may be a sign of an infection.

– If you are diabetic, and your blood sugars become elevated at home, this may also be a sign of infection. (Elevation in the first few days is normal, and is often treated with insulin – particularly if you are in the hospital.

– Pain that persists beyond 3 months may be a sign of nerve damage (and you will need additional medications / therapies).

Dental hygeine and post-operative pneumonia in esophageal cancer patients

In an investigational study, Akutsu et. al. (2010) demonstrated a significant reduction in post-operative pneumonia through the implementation of a dental hygiene program.

A Japanese study suggests that one of the most important ways to reduce post-operative risk is also the easiest – by practicing good dental hygiene. While research has previously linked coronary artery disease (CAD) with dental plaque and chronic gum inflammation – two articles by Akutsu et. al (2010) in Japan have shown a reduction in post-operative pneumonia in esophageal cancer patients through the use of dental hygiene regimens.

The first of these articles in an overview of several factors to reduce post-operative risk, and was previously mentioned in another post:

Akutsu, Y. & Matsubara, H. (2009) Perioperative Management for the Prevention of Postoperative Pneumonia with Esophageal Surgery. Ann Thorac Cardiovasc Surg. 2009 Oct;15(5):280-5. (free full text). This is a well written report by Japanese surgeons on several techniques to reduce post-operative pneumonia. Several of these items can be directly implemented by patients – such as pre-operative smoking cessation, pulmonary rehabilitation and good dental hygiene.

The second article, “Pre-operative dental brushing can reduce the risk of post-operative pneumonia in esophageal cancer patients” was published in Surgery (2010, Apr; 147(4) 497-502.) The authors conducted an investigational study using 86 thoracic surgery patients scheduled to undergo esophagectomy. A control group of 41 patients and the dental hygiene (treatment) group consisting of 45 patients.

The dental hygiene group underwent no special dental procedures or cleanings but were instructed to brush their teeth five times a day.

The results showed a dramatic decrease in the incidence of post-operative pneumonia in the treatment group. 32% of the control group developed pneumonia post-operatively compared to only 9% of the toothbrushing group. 12% of the patients in the control group required tracheostomy due to the development of pneumonia (and prolonged respiratory support). No members of the treatment group required tracheostomy.

While the study size is relatively small – the results show an impressive reduction in post-operative pneumonia for a fairly small investment (increased tooth brushing/ dental hygiene.)

Esophageal surgery and esophageal surgery centers

Discussion of article by Bilimoria and the importance of high volume esophageal surgery programs for successful post-operative outcomes.

Here’s another study highlighting the importance of having esophagectomies (esophageal surgery) at high volume centers. It’s a topic we’ve talked about before, and as it’s something I feel very strongly about – something readers will probably see mentioned again. It also helps answer the question – “Do I need to travel to X for surgery or can I have it at the local hospital?” This was the main questions the researchers were looking at for this study in terms of costs, logistics and burdens on patient and family.

This article by Bilimoria et. al (2010), published in the Annals of Surgery, was actually comparing outcomes for multiple surgery types at small community hospital versus large specialty center, not just thoracic surgeries but the research findings are similar to what we have reported previously. The irony of this study is that the researchers were expressly trying to prove the opposite, that small hospitals are safe for high complexity, high morbidity/ mortality operations – as a way to cut costs, and save money by preventing additional patient shifting to larger institutions that may be at a considerable distance for patients. They demonstrated limited success in their results for other surgeries – but the need for high volume esophagectomy programs for successful surgical outcomes remains unchanged. (Some of this may be due to the fact that many of these esophagectomies at smaller hospitals are performed by general, not thoracic surgeons.)

The answer for patients with esophageal cancer is: Yes – you do need to go to the esophageal cancer center (not your local community hospital). This is regardless of classification of low or high risk (which is based on age, and a Charlson score – which is a score used to add up other risk factors). This is something I have had to address with patients in my own personal practice as both a referring provider (at a smaller facility) and as a receiving provider (when I was at a larger esophageal surgery center.)

I’ve reposted the abstract below, so you can read for yourself. (The article itself is several pages long). [Italics are mine..]

Bilimoria, et. al. (2010). Risk-based Selective Referral for Cancer Surgery: A Potential Strategy to Improve Perioperative Outcomes Annals of Surgery. 2010;251(4):708-716.

Abstract

Background: Studies have demonstrated volume-outcome relationships for numerous operations, providing an impetus for regionalization; however, volume-based regionalization may not be feasible or necessary. Our objective was to determine if low-risk patients undergoing surgery at Community Hospitals have perioperative mortality rates comparable with Specialized Centers.

Methods: From the National Cancer Data Base, 940,718 patients from ~1430 hospitals were identified who underwent resection for 1 of 15 cancers (2003–2005). Patients were stratified by preoperative risk according to age and comorbidities. Separately for each cancer, regression modeling stratified by high- and low-risk groups was used to compare 60-day mortality at Specialized Centers (National Cancer Institute-designated and/or highest-volume quintile institutions), Other Academic Institutions (lower-volume, non-National Cancer Institute), and Community Hospitals.

Results: Low-risk patients had statistically similar perioperative mortality rates at Specialized Centers and Community Hospitals for 13 of 15 operations. High-risk patients had significantly lower perioperative mortality rates at Specialized Centers compared with Community Hospitals for 9 of 15 cancers. Regardless of risk group, perioperative mortality rates were significantly lower for pancreatectomy and esophagectomy at Specialized Centers. Risk-based referral compared with volume-based regionalization of most patients would require fewer patients to change to Specialized Centers.

Conclusions: Perioperative mortality for low-risk patients was comparable at Specialized Centers and Community Hospitals for all cancers except esophageal and pancreatic, thus questioning volume-based regionalization of all patients. Rather, only high-risk patients may need to change hospitals. Mortality rates could be reduced if factors at Specialized Centers resulting in better outcomes for high-risk patients can be identified and transferred to other hospitals.

Pre & Post-operative Surgical Optimization for Lung Surgery

How to maximize your chances before lung surgery to speed healing, post-operative recovery and reduce the incidence of complications.

As most of my patients from my native Virginia can attest; pre and post-operative surgical optimization is a critical component to a successful lung surgery. In most cases, lung surgery is performed on the very patients who are more likely to encounter pulmonary (lung) problems; either from underlying chronic diseases such as emphysema, or asthma or from the nature of the surgery itself.

Plainly speaking: the people who need lung surgery the most, are the people with bad lungs which makes surgery itself more risky.

During surgery, the surgeon has to operate using something called ‘unilung ventilation’. This means that while the surgeon is trying to get the tumor out – you, the patient, have to be able to tolerate using only one lung (so he can operate on the other.)

Pre-surgical optimization is akin to training for a marathon; it’s the process of enhancing a patient’s wellness prior to undergoing a surgical procedure. For diabetics, this means controlling blood sugars prior to surgery to prevent and reduce the risk of infection, and obtaining current vaccinations (flu and pneumonia) six weeks prior to surgery. For smokers, ideally it means stopping smoking 4 to 6 weeks prior to surgery.(1) It also means Pulmonary Rehabilitation.

Pulmonary Rehabilitation is a training program, available at most hospitals and rehabilitation centers that maximizes and builds lung capacity. Numerous studies have show the benefits of pre-surgical pulmonary rehabilitation programs for lung patients. Not only does pulmonary rehabilitation speed recovery, reduce the incidence of post-operative pneumonia,(2) and reduce the need for supplemental oxygen, it also may determine the aggressiveness of your treatment altogether.

In very simple terms, when talking about lung cancer; remember: “Better out than in.” This means patients that are able to have surgical resection (surgical removal) of their lung cancers do better, and live longer than patients who receive other forms of treatment such as chemotherapy or radiation.

If you are fortunate enough to have your lung cancer discovered at a point where it is possible to consider surgical excision – then we need you to take the next step, so you are eligible for the best surgery possible.

We need you to enhance your lung function through a supervised walking and lung exercise program so the surgeon can take as much lung as needed. In patients with marginal lung function,(3) the only option is for wedge resection of the tumor itself. This is a little pie slice taken out of the lung, with the tumor in it. This is better than chemotherapy or radiation, and is sometimes used with both – but it’s not the best cancer operation because there are often little, tiny, microscopic tumor cells left behind in the remaining lung tissue.

The best cancer operation is called a lobectomy, where the entire lobe containing the tumor is removed. (People have five lobes, so your lung function needs to be good enough for you to survive with only four.(4) This is the best chance to prevent a recurrence, because all of the surrounding tissue where tumors spread by direct extension is removed as well. Doctors also take all the surrounding lymph nodes, where cancer usually spreads to first. This is the best chance for five year survival, and by definition, cure. But since doctors are taking more lung, patients need to have better lung function , and this is where Pulmonary Rehab. comes in. In six weeks of dedicated pulmonary rehab – many patients who initially would not qualify for lobectomy, or for surgery at all – can improve their lung function to the point that surgery is possible.

Post-operatively, it is important to continue the principles of Pulmonary rehab with rapid extubation (from the ventilator), early ambulation (walking the hallways of the hospitals (5) and frequent ‘pulmonary toileting’ ie. coughing, deep breathing and incentive spirometry.

All of these things are important, where ever you have your surgery, but it’s particularly important here in Bogota due to the increased altitude.

One last thing for today:
a. Make sure to have post-pulmonary rehab Pulmonary Function Testing (PFTs, or spirometry) to measure your improvement to bring to your surgeon,
b. walk daily before surgery (training for a marathon, remember)

c. bring home (and use religiously!) the incentive spirometer provided by rehab.

ALL of the things mentioned here today, are things YOU can do to help yourself.

Footnotes:
1. Even after a diagnosis of lung cancer, stopping smoking 4 to 6 weeks before surgery will promote healing and speed recovery. Long term, it reduces the risk of developing new cancers.

2. Which can be fatal.

3. Lung function that permits only a small portion (or wedge section) to be removed

4. A gross measure of lung function is stair climbing; if you can climb three flights of stairs without stopping, you can probably tolerate a lobectomy.

5. This is why chest tube drainage systems have handles. (so get up and walk!)

Additional References:

Smoking and post-operative complications