Dissertations / Theses on the topic 'Thoracotamy'

Little is known about the recovery of patients after pneumonectomy and the impact of the surgery on the lifestyle of young, employed, ex-smokers and their families. This study was conducted to address this knowledge deficit, and gather information that would help health professionals to be able to assist people facing pneumonectomy. A qualitative study using van Manens methodological approach to interpretive phenomenology was chosen, in order to capture a full and rich understanding and meaning of the phenomenon that patients live. The names, age, operation, histological cell type, stage of disease, and disease free status of potential participants were obtained from a Lung Cancer Surgical Database after obtaining ethical approval for the study. Nine participants (three females and six males) met the inclusion criteria and gave informed consent for the study. Data collection comprised of open-ended interviews that were audiotaped, then transcribed verbatim into hard data. Data interpretation was based on the selective reading approach of van Manen from which six thematic statements arose. These are living the discomforts of treatment and recovery, discovering new limitations on myself; functional and emotional, my reliance on support, my financial security is threatened, my survival is at threat, and I wish I had known more. The study found that each participant had a unique experience of recovery and consequently the degree of recovery attained varied between participants. They all had a very strong desire to survive lung cancer and considered the risks of major surgery and loosing a lung to be insignificant compared to the certainty of loosing their life if they did not undergo surgery. This study provided a glimpse of what it was like for a group of patients to live the experience of life after a pneumonectomy and it provides a basis from which nurses can explore further the experiences of patients who are subjected to lung cancer surgery.

Little is known about the recovery of patients after pneumonectomy and the impact of the surgery on the lifestyle of young, employed, ex-smokers and their families. This study was conducted to address this knowledge deficit, and gather information that would help health professionals to be able to assist people facing pneumonectomy. A qualitative study using van Manens methodological approach to interpretive phenomenology was chosen, in order to capture a full and rich understanding and meaning of the phenomenon that patients live. The names, age, operation, histological cell type, stage of disease, and disease free status of potential participants were obtained from a Lung Cancer Surgical Database after obtaining ethical approval for the study. Nine participants (three females and six males) met the inclusion criteria and gave informed consent for the study. Data collection comprised of open-ended interviews that were audiotaped, then transcribed verbatim into hard data. Data interpretation was based on the selective reading approach of van Manen from which six thematic statements arose. These are living the discomforts of treatment and recovery, discovering new limitations on myself; functional and emotional, my reliance on support, my financial security is threatened, my survival is at threat, and I wish I had known more. The study found that each participant had a unique experience of recovery and consequently the degree of recovery attained varied between participants. They all had a very strong desire to survive lung cancer and considered the risks of major surgery and loosing a lung to be insignificant compared to the certainty of loosing their life if they did not undergo surgery. This study provided a glimpse of what it was like for a group of patients to live the experience of life after a pneumonectomy and it provides a basis from which nurses can explore further the experiences of patients who are subjected to lung cancer surgery.

Background: Venous thromboembolism, manifesting as deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant source of morbidity and mortality and a cause of postoperative complications after invasive surgery. These adverse events are more likely to occur in high risk patients, such as those with cancer or undergoing major surgery with the highest incidence peak taking place within the first month after surgery. Despite the issue being globally recognized, a lack of consensus regarding guidelines for prophylaxis post-discharge still exists. Aim: To determine the incidence of venous thromboembolism within a 30-day postoperative period after thoracotomy and lung lobectomy for lung malignancy, to assess a correlation of the above with administered prophylactic treatment. Method: A retrospective cohort study was conducted as a review of medical records of all patients, appertaining to Örebro county, who had undergone thoracotomy and lung lobectomy for lung cancer or secondary malignant tumor in the lung, during 2015-2017 at the department of Cardiothoracic and Vascular Surgery, Örebro University Hospital. An internally validated register was used to identify the patient population and partial collection of the data. Results: Of the 67 included patients 50,8% were men and the mean age of the population was 67,5 years. The VTE prevalence during the 30-day postoperative period was 1,5%. A total of 59,7% of the patients received thrombosis prophylaxis preoperatively, 98,1% postoperatively and 11,9 % after hospital discharge. Conclusion: The VTE prevalence of 1,5% in this study may suggest the current postoperative prophylactic regiment successful, yet VTE remains a clinically significant complication, and the need for well-defined guidelines is evident.

Ingrepp som thoracotomi och skopi är kända för att orsaka patienterna svår smärta och stort lidande. Inom anestesisjuksköterskans område ligger att ansvara för dessa patienter perioperativt. Perioperativ vård syftar till att ge patienten trygghet, kontinuitet, ge en helhetssyn, förbättra kommunikationen och minska patientens lidande samt kvalitessäkra vården. Till hjälp har anestesisjuksköterskan behandlingsriktlinjer till grund för den perioperativa vården. Kliniska evidensbaserade riktlinjer är grundläggande instrument för att säkerställa vårdkvalitet för den enskilda patienten så att vården utförs efter bästa tillgängliga kunskap och beprövad erfarenhet. Studiens syfte var att granska och bedöma de kliniska behandlingsriktlinjerna med avseende på patienter som genomgår thoracotomi och skopi som idag används på svenska och norska thoraxkirurgiska kliniker.Studien utfördes enligt kvantitativ metod och presenterades deskriptivt där resultatet redovisades i siffror och tabeller med förklarande text. Ett brev skickades ut till samtliga Sveriges och Norges thoraxkirurgiska kliniker varav svarsfrekvensen uppgick till 50%. Författarna erhöll sex av totalt tolv tänkbara riktlinjer. Granskningen av behandlingsriktlinjerna utfördes med hjälp av granskningsinstrumentet AGREE II. Samtliga thoraxkirurgiska kliniker hade riktlinjer och dessa som kom till författarnas kännedom var relativt lika med avseende på behandling och interventioner. Resultatet visar att samtliga thoraxkirurgiska kliniker saknade behandlingsriktlinjer som kan rekommenderas eftersom de inte bygger på dokumenterad evidens. Endast två av områdena hade riktlinjer som författarna kan rekommendera efter viss modifikation. Samtliga riktlinjer hade metodologiska brister i rapporteringen om hur riktlinjen togs fram och detta utgör ett hinder för att behandlingsriktlinjerna ska kunna utgöra den kvalitetssäkring de är avsedda att vara. Evidensen som ligger till grund för riktlinjen bör synliggöras och det är viktigt att patientgruppens åsikter och preferenser i framtagandet tas i beaktande. Den perioperativa vården som riktlinjerna beskriver finns väl dokumenterad i litteratur och riktlinjerna hade fått ett högre värde om kopplingen mellan åtgärder och evidens dokumenterats. Med tanke på att tusentals lungpatienter opereras årligen anser författarna att de riktlinjer som vården grundar sig på självklart skall bygga på aktuell forskning och evidens.
Program: Specialistsjuksköterskeutbildning med inriktning mot anestesisjukvård

Background and Objectives: The pathophysiology of post-operative pneumonia following lung resection is poorly understood despite it being the most common complication which may lead to death. The role of the acute inflammatory response following lung resection, in particular innate immune cells, was investigated and used to identify biomarkers for post-operative pneumonia. Comparison of inflammatory responses to resection undertaken by video-assisted thorascopic surgery (VATS) and thoracotomy was also evaluated. Methods: Patients undergoing lung resection for suspected bronchogenic carcinoma were recruited. Objective pre-defined criteria were used to diagnose pneumonia. Bronchoalveolar lavage (BAL) was conducted in the contra-lateral lung pre- and postoperatively to measure cellular composition and cytokines. Blood was sampled preoperatively and 6-, 24- and 48-hours post-operatively primarily to assess neutrophil phagocytic capacity, monocyte subsets, monocyte cytokine responses to lipopolysaccharide (LPS) stimulation and serum cytokine responses. Exhaled nitric oxide (eNO) was also measured at these time points. Patient groups were compared using paired or student t-tests together with ANOVA/ANCOVA modelling. The predictive strength of the biomarkers identified was tested. Results: 40 patients were recruited. 26 patients (65%) underwent major lung resection using VATS and 14 (35%) thoracotomy. There was a post-operative blood monocytosis (p<0.0005) with an absolute expansion of classical and intermediate monocytes (p=0.001) and a relative fall in non-classical monocytes (p<0.005). Post-operatively blood monocytes became more pro-inflammatory with an overall significant increase in IL-8 (p=0.034) and TNF-α (p=0.028) together with an increase in IL-6 (p=0.028) and IL-10 by 48 hours (p=0.010). VATS was associated with a smaller release of IL-10 only (p=0.011). There was a general trend towards post-operative reduction in neutrophil phagocytosis of zymosan (in suspension) on ANOVA modelling (p=0.047). Lung resection led to an increase in serum cytokines IL-6, IL-8 and IL-10 which peaked at 24hrs before falling (p<0.0005). ANOVA modelling confirmed significantly lower levels of serum cytokines in VATS patients compared with thoracotomy (p=0.026 for IL-6, p=0.018 for IL-8 p=0.047 for IL-10). No significant post-operative change was found for IL-1β, TNF-α and IL-12p70 (p>0.05). Bronchoalveolar lavage fluid (BALF) and blood samples demonstrated a relative post-operative leucocytosis due principally to neutrophilia. A relative blood lymphopenia and thrombocytopenia developed postoperatively (p<0.0005). VATS was associated with a lower fall in serum albumin (p=0.001). BALF from the non-operated lung became more pro-inflammatory immediately post-operatively with an increase in IL-6 (p<0.0005), IL-8 (p=0.017), IL- 10 (p=0.018) and IL-1β (p=0.002). eNO tended to fall post-operatively which reached significance at 48 hrs (p=0.029). 14 patients developed pneumonia. Pre-operatively, a blood neutrophil count above 5.04x109/L had a relative risk (RR) for pneumonia of 3.3 (95% confidence interval (CI95) 1.1-10.1), and a BAL cell count of greater than 1.04x105/ml had a RR of 3.4 (CI95 1.3-9.0), whilst LPS-stimulated monocyte secretion of IL-12 of less than 0.15 pg/ml/μg protein had a RR of 3.0 (CI95 1.2-7.3). At 24 hours post-operatively, LPS-stimulated release from monocytes of IL-10 greater than 1.99 pg/ml/μg protein (RR 4.1, CI95 1.3- 12.3) and IL-6 greater than 414 pg/ml/μg protein (RR 3.1, CI95 1.2-8.1) were predictive of pneumonia. Conclusion: Lung resection is associated with significant early pro- and antiinflammatory responses. VATS resection invoked significantly lower levels of serum cytokines and albumin changes compared with thoracotomy suggesting VATS lobectomy should be the surgical treatment strategy of choice for early stage lung cancer. No difference in neutrophil function or monocyte function was however observed between the surgical groups. Clinical benefits of this reduced inflammation need to be evaluated in a larger cohort of patients. Relative pre-operative leucocytosis in blood and BAL together with monocyte hyper-responsiveness in the early postoperative period is associated with the development of pneumonia. These findings warrant further investigation for their predictive power in accurately identifying postoperative pneumonia. Ultimately, they may be incorporated into a risk stratification model enabling targeted prophylactic or earlier therapeutic intervention.

Objetivo: Avaliar os efeitos da estimulação elétrica nervosa transcutânea (TENS) comparada com TENS placebo e grupo controle sobre a dor, função pulmonar, força muscular respiratória e medicações analgésicas no pós-operatório de cirurgias torácicas em uma Unidade de Tratamento Intensivo (UTI). Método: Pacientes entre 31 e 76 anos submetidos a toracotomia póstero-lateral, foram incluídos e alocados aleatoriamente em três grupos: TENS (GE), TENS placebo (GP) e controle (GC). O GE recebeu a aplicação da TENS (frequência=100 Hz, duração de pulso=100 μs, intensidade no nível sensorial, durante 30 minutos, três vezes ao dia, durante a internação na UTI), associada a fisioterapia convencional (respiratória e motora). No GP foi realizada a TENS placebo além de fisioterapia convencional; e o GC recebeu apenas a fisioterapia convencional. Os desfechos foram avaliados no pré-operatório, pós-operatório (PO), e 48 horas após a internação na UTI: dor através da Escala Visual Analógica, função pulmonar através de espirometria (VEF1 e CVF), força muscular respiratória através de manovacuometria (PImáx e PEmáx), e medicações através da análise dos prontuários. Resultados: Foram incluídos 45 pacientes, sendo 15 em cada grupo. Em relação a percepção dolorosa, não houve diferença entre os grupos (P=0,172), porém houve redução na dor após o término do primeiro atendimento no GE (4,7±3,2 vs. 3,3±2,6; P<0,05). Em relação a função pulmonar e força respiratória não houve diferença significativa entres os grupos nos momentos avaliados. Entretanto, nas avaliações intragrupo, observou-se melhora na CVF, todos os grupos apresentaram redução no momento PO e 48 horas comparado com o pré (P<0,001), e somente o GE promoveu um aumento na CVF nas 48 horas em relação ao PO (P<0,001). A PImáx e PEmáx diminuíram em todos os grupos comparando o pré com o PO e 48 horas (P<0,001). Não houve diferença entre os grupos em relação as medicações analgésicas, porém o GC apresentou maior consumo de morfina (p=0,037) e o GP maior consumo de paracetamol (p=0,035) 24 vs 48 horas, o que não foi alterado no GE. Conclusão: Não foi observado diferença entre os grupos em relação aos desfechos avaliados no pós-operatório de cirurgia torácica, porém, a TENS 13 promoveu redução da dor e aumento mais precoce da CVF, além disso, não promoveu aumento no consumo de medicação.
Objective: To evaluate the effects of transcutaneous electrical nerve stimulation (TENS) compared to placebo TENS and control group on pain, pulmonary function, respiratory muscle strength and analgesic medications in the postoperative period of thoracic surgery in an Intensive Care Unit (ICU). Methods: Patients between 31 and 76 years submitted to postero-lateral thoracotomy, were included and randomly allocated into three groups: TENS (GE), TENS placebo (GP) and control (GC). The GE received TENS (frequency = 100 Hz, pulse duration = 100 μs, intensity at the sensory level for 30 minutes, three times a day during ICU stay), associated with conventional physiotherapy (respiratory and motor). In GP, TENS was performed in addition to conventional physiotherapy; And GC received only conventional physiotherapy. The outcomes were evaluated in the preoperative, postoperative (PO) or 24 hours, and 48 hours after ICU admission: Pain through Visual Analog Scale, pulmonary function through spirometry (FEV 1 and FVC), respiratory muscle strength Through manovacuometry (MIP and MEP), and medications through the analysis of medical records. Results: 45 patients were included, 15 in each group. Regarding pain perception, there was no difference between the groups (P = 0.172), but there was a reduction in pain after the end of the first treatment in the GE (4.7 ± 3.2 vs. 3.3 ± 2.6; P <0.05). Regarding pulmonary function and respiratory force, there was no significant difference between the groups at the moments evaluated. However, in the intragroup evaluations, improvement in FVC, all the groups had a reduction at the time PO and 48 hours compared to the pre (P <0.001), and only the GE promoted an increase in FVC at 48 hours in relation to PO (P <0.001). The MIP and MEP decreased in all groups comparing the pre with PO and 48 hours (P <0.001).There was no difference between the groups in relation to analgesic medications, however, the CG had higher morphine consumption (p = 0.037) and the GP had a higher paracetamol consumption (p = 0.035) 24 vs 48 hours, which was not altered in the GE. Conclusion: No differences were observed between the groups in relation to the outcomes evaluated in the postoperative period of thoracic surgery, however, TENS promoted pain reduction and earlier increase in FVC, in addition, did not promote increase in medication consumption.

Orientadores: Ivan Felizardo Contrera Toro, Ivete Alonso Bredda Saad
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: Introdução: A aplicação de ventilação mecânica não invasiva (VMNI) no período pós-operatório (POS) pode restaurar a capacidade residual funcional, melhorar a oxigenação e poupar os músculos inspiratórios. Objetivos: Verificar e comparar a evolução de variáveis espirométricas, da gasometria arterial, do pico de fluxo expiratório (PFE), da dispneia e do relato de dor, além do tempo de permanência e borbulhamento dos drenos torácicos em dois grupos no POS de ressecção pulmonar: fisioterapia respiratória convencional (FRC) e a associação desta à pressão positiva contínua nas vias aéreas (CPAP). Método: Estudo prospectivo, intervencionista e não randomizado. A avaliação pré-operatória (PRE) constituiu-se da execução da Prova de Função Pulmonar (PFP), da gasometria arterial, do PFE e relato de dispneia, além da realização de espirometria de incentivo, e orientações quanto ao procedimento cirúrgico. Os atendimentos nos grupos FRC e CPAP foram realizados no POS imediato (POSi), primeiro e segundo POS (POS 1, POS2), e a reavaliação na alta hospitalar ou quinto POS . A VMNI foi aplicada durante duas horas e o ajuste pressórico estabelecido entre 7 e 8,5 cmH2O, sendo aumentado conforme tolerância do paciente. Foram analisados o Índice de Oxigenação (IO), relato de dor, presença e borbulhamento dos drenos, e as mesmas variáveis do PRE. Resultados: Houve diferença, entre os grupos, no borbulhamento do dreno anterior no POSi e POS1 (p=0,001 e p=0,012), e para o dreno posterior no POSi (p=0,036). Na análise intra grupo (FRC) verificou-se redução do IO entre PRE e POS1 (p=0,042), e, inter grupo houve aumento no grupo CPAP no POSi (p=0,035). Não houve diferenças significativas entre os dois grupos com relação à escala analógica de dor. Ao se verificar a dispneia no POSi e POS1 observaram-se diferenças significativas entre os grupos (p<0,001). Na análise entre os períodos observaram-se reduções significativas do VEF1 e CVF em ambos os grupos, com p<0,001. O PFE não apresentou diferença significativa entre os grupos (p=0,064). Conclusão: A aplicação preventiva da CPAP no POS de ressecção pulmonar proporcionou melhora da oxigenação sem aumento da perda aérea pelos drenos de tórax
Abstract: Introduction: The application of noninvasive ventilation (NIV) during the postoperative period (POS) can restore functional residual capacity, improve oxygenation and spare inspiratory muscles. Objectives: To determine and compare the evolution of spirometric variables, blood gases, peak expiratory flow (PEF), dyspnea and report of pain, and length of stay and bubbling of chest tubes in two postoperative groups of lung resection: chest physiotherapy (CP) and its association with continuous positive airway pressure (CPAP). Method: Prospective, and not randomized controlled trial. The preoperative evaluation (PRE) consisted of collection of Pulmonary Function Test, arterial blood gas analysis, the report of dyspnea, PEF, and performing such incentive spirometry, and information about the surgical procedure. Primary care groups CP and CPAP were performed in the immediately POS (POSi), first and second POS (POS1, POS2), and reassessment on discharge or fifth POS. NIV was applied for two hours and the pressure adjustment set between 7 and 8.5 cmH2O, and it was increased as the patient's tolerance. Were analyzed the oxygenation index (OI), reporting pain, presence and bubbling of drains, and the same variables from PRE. Results: There were differences between groups in the bubbling of the anterior drain in POSi and POS1, (p = 0.001 and p = 0.012), and for the posterior drain just in POSi (p = 0.036). In intra-group analysis (CP) showed a reduction of OI between PRE and POS1 (p = 0.042), and inter group increased in the CPAP group in the POSi (p = 0.035). There were no significant differences between the two groups to analog pain scale. For the dyspnea in POSi and POS1 were observed significant differences between groups (p <0.001). In the analysis between the periods observed significant reductions in FEV1 and FVC in both groups, p <0.001. The PEF was not significantly different between groups (p = 0.064). Conclusion: The application of CPAP in preventive postoperative pulmonary resection resulted in improved oxygenation without increasing air leaks through the thoracic drains
Mestrado
Fisiopatologia Cirúrgica
Mestre em Ciências

Habilitacijos procedūrai teikiamoje mokslo darbų apžvalgoje apibendrinama Vilniaus universiteto Širdies ir kraujagyslių ligų klinikos Širdies chirurgijos centro patirtis, pakartotinai operuojant ligonius po širdies vožtuvų protezavimo. Įvertintas mažai trombogeniškų protezų efektyvumas. Nustatyta, kad labai sunkių ligonių su infekuotais protezais mirštamumas nemažėja, nors pastaraisiais metais daugiau operuojame III funkcinės klasės ligonių ir jų operacijų rezultatai puikūs. Dėl pasiūlyto radikalesnio triburio vožtuvo nesandarumo gydymo pirminių operacijų metu, efektyviai mažėja pakartotinių šio vožtuvo operacijų. Įteisinta planinė seno rutulinio protezo pakeitimo operacija. Įdiegti nauji širdies pjūviai, įdiegtos krūtinės ląstos pjūvių atlikimo metodikos, farmakologiniai ir nefarmakologiniai perioperacinio kraujavimo stabdymo būdai efektyviai sumažina kraujavimo pavojų. Pasiūlytas originalus kairio skilvelio drenavimo būdas per atskira torakotominį pjūvį padeda sumažinti pooperacinį širdies nepakankamumą. Šiame darbe remiuosi kartu su bendradarbiais atliktų operacijų rezultatais. Šiuo metu kaip skyriaus, kuriame gydomi ligoniai su vožtuvų patologija, vadovas atlieku daugiau kaip pusę pakartotinių operacijų. Moksliniai pranešimai apie pakartotinių operacijų rezultatus buvo daryti Lietuvos, Pasaulio ir Europos kongresuose ir suvažiavimuose.
The review of scientific work presented for habilitation procedure summarizes the experience of redo operations of patients after replacement of heart valves accumulated at the Heart Surgery Centre of Vilnius University Clinic of Angiology and Cardiology. The efficacy of low thrombogenicity valve prostheses was evaluated. It was found out that the mortality rate of very severely ill patients with infected did not decrease; however the larger number of patients in functional class III were being operated during the period of recent years and the results of these operations were excellent. The rate of redo tricuspid valve operations had decreased effectively because of more radical surgery treatment of this valve during the primary operation. The operation of replacement of old ball prosthesis has been validated. The new incisions of the heart were introduced as well as new methods of performance of chest box incisions and pharmacologic and non-pharmacologic methods of perioperative hemostasis; the methods mentioned above effectively reduced the risk of bleeding. The original method of the left ventricle venting via separate thoracotomy incision enabled to reduce postoperative heart failure. This work is based on the results of operations performed in cooperation with co-workers. As a chief of the department where the patients with pathology of heart valves are treated, I am performing more than a half of redo operations. The scientific presentations concerning the results of... [to full text]

Prema literaturnim podacima poslednjih godina velika pažnja je usmerena ka operativnom riziku i mortalitetu koji su postali najvažniji kriterijumi u ocenama rezultata rada hirurških ustanova, ali i svakog hirurga posebno. Zahvaljujući kompleksnom profilu pacijenata koji se podvrgavaju hirurškim intervencijama, precizna procena operativnog rizika postaje sve teža. Predikcija ishoda intervencije u najvećoj meri zavisi od preoperativnih faktora rizika. Ipak, neminovno je da i faktori koji su vezani za samu operaciju u određenom stepenu utiču na ishod hirurške intervencije. Shodno tome, dobar model za procenu rizika treba da obuhvati faktore koji će imati najbolju prediktivnu vrednost. Thoracoscore je prvi bodovni sistem razvijen od strane Francuskog udruženja grudnih i vaskularinih hiruga. Zbog nedovoljne primene tokom poslednje decenije i nekonzistentnih rezultata nije došlo do širokog međunarodnog prihvatanja ovog modela i njegove rutinske upotrebe. Ova činjenica ukazuje na nedostake samog modela i potrebu za rekalibracijom u cilju postizanja bolje saglasnosti između predikcije operativnog rizika i kliničkog stanja bolesnika. Cilj rada je bio da se ustanovi realna vrednost Thoracoscore bodovnog sistema u proceni operativnog rizika i mortaliteta nakon anatomskih i neanatomskih resekcija pluća u našim uslovima, i da se utvrdi prediktivna vrednost faktora rizika koji nisu obuhvaćeni Thoracoscore bodovnim sistemom na ishod grudno-hirurških operacija. Istraživanje je sprovedeno po tipu prospektivne kliničke studije i obuhvatilo je 957 bolesnika operisanih na Klinici za grudnu hirurgiju Instituta za plućne bolesti Vojvodine. Izvršene hirurške procedure bile su anatomske resekcije (lobektomija, bilobektomija, pneumonektomija, Sleeve resekcija, segmentektomija) i neanatomske resekcije pluća (Wedge resekcija i druge atipične resekcije). Thoracoscore je izračunat za svakog bolesnika na osnovu devet parametara: godine starosti, pol, ASA skor, dispnea skor, procena opšteg stanja bolesnika, dijagnostička grupa, hitnost operacije, vrsta operacije i broj komorbiditeta. S obzirom da prediktivna vrednost Thoracoscore bodovnog sistema u proceni operativnog rizika nije bila adekvatna realnom stanju, regresionom analizom je evaluiran značaj tri nova faktora: forsirani ekspiratorni volumen u prvoj sekundi (FEV1), reoperacija i hirurški pristup (torakotomija, video-asistirana torakoskopija – VATS). Nakon što je univarijantnom analizom potvrđeno da su ovi faktori nezavisni prediktori operativnog ishoda, originalni Thoracoscore model je rekalibrisan. Multivarijantnom analizom putem logističke regresije izračunati su novi beta koeficijenti za originalnih devet faktora, kao i za tri nova, te je kreiran lokalni model za procenu operativnog rizika koji je prilagođen našoj populaciji. Prosečna starosti bolesnika bila je 62 ± 7,52 godina. Većinu uzorka (60,7%) činili su pripadnici muškog pola. Najveći broj resekcija činile su lobektomije (61,4%). Malignitet je bio najučestalija indikacija za operaciju (90,3%). Najveći broj bolesnika imao je 1-2 komorbiditeta (64,3%). Prosečna stopa operativnog rizika na osnovu Thoracoscore-a (4,7% ) bila je veća je od stvarnog (2,9%) intrahospitalnog mortalita (p<0,01). Ovaj model je pokazao zadovoljavajuće rezultate jedino u grupi niskog rizika. Predikcija mortaliteta lokalnim modelom za procenu operativnog rizika u grudnoj hirurgiji se, u statističkom smislu, ne razlikuje od stvarnog mortaliteta (p = NS). Thoracoscore ima dobru diskriminativnu moć, ali nezadovoljavajuću kalibrisanost. Shodno tome, Thoracoscore model se može koristiti za stratifikaciju rizika, ali ne i za predikciju mortaliteta. Za razliku, lokalni model je pokazao dobru diskriminaciju i kalibrisanost u našim uslovima. Interni model za procenu rizika bi bio od velike koristi u svakodnevnom kliničkom radu, budući da bi oslikavao realno stanje populacije u kojoj je razvijen i vršio preciznu predikciju operativnog rizika.
According to the literature data, over the past several years, great attention has been focused on operative risk and mortality which have become the most important criteria in evaluating the results from surgical departments and individual surgeons, as well. Because of complex profiles of patients undergoing surgical interventions, it is becoming more difficult to assess the risk precisely. Prediction of surgical outcomes mostly depends on the preoperative risk factors. However, factors related to the procedure itself effect the surgical outcome to a certain degree. Therefore, a good risk assessment model must contain factors which will have the best predictive value. Thoracoscore is the first scoring system developed by the French Association of Thoracic and Vascular Surgeons. Due to insufficient utilization over the past decade and inconsistent results, this model has not been widely accepted for routine use. This fact indicates that the model lacks certain aspects and needs to be recalibrated in order to achieve better concordance between the predicted operative risk and the clinical state of the patient. The aim of this study was to determine real value of Thoracoscore scoring system for estimation of operative risk and mortality following anatomic and non-anatomic lung resections in our settings, and to determine predictive value of factors not included in Thoracoscore on the outcome of thoracic surgeries. This prospective study included 957 patients who underwent lung resections at the Thoracic surgery clinic of Institute for Lung Diseases of Vojvodina. Performed surgical procedures were anatomic lung resections (lobectomy, bilobectomy, pneumonectomy, Sleeve resection, segmentectomy) and non-anatomic lung resections (Wedge resection and other atypical resections). Thoracoscore was calculated for each patient based on the following nine parameters: age, gender, ASA score, dyspnea score, performance status classification, diagnostic group, urgency of surgery, surgical procedure and number of comorbidities. Because predictive value of Thoracoscore did not correspond to the actual results, regression analysis was used to evaluate the significance of three new risk factors: forced expiratory volume in the first second (FEV1), reoperation, and surgical approach (thoracotomy, video-assisted thoracoscopy – VATS). After univariate analysis confirmed that these three factors are independent predictors of operative risk, the original Thoracoscore model was recalibrated. With the use of multivariate analysis by logistic regression, new beta coefficients were calculated for the original nine parameters, as well as for the new three, and consequently a local model for surgical risk assessment that is adapted to our population was created. Average age of patients was 62 ± 7.52 years. Most of the patients were males (60.7%). Lobectomies constituted the largest number (61.4%) of performed surgeries. The most common indications for surgery were malignant causes (90.3%). Most frequently, patients had 1-2 comorbidities (64.3%). Mean operative risk based on Thoracoscore (4.7%) was greater than the actual intrahospital mortality (2.9%) (p<0.01). This model had adequate results only in the low risk group of patients. Predicted mortality by the local model was not statistically different from the actual mortality (p = NS). Thoracoscore had good discriminative ability, but inadequate calibration. Because of this, Thoracoscore model can be used for risk stratification, but not for mortality prediction. On the other hand, local model showed good discrimination and calibration in our population. Therefore, an internal model for risk assessment would be of great use in everyday clinical practice because it would reflect the real state of the population in which it was developed, predicting the risk more precisely.

碩士
中國醫藥大學
復健科學研究所碩士班
106
Background: Although advances in analgesia techniques have alleviated the acute pain that occurs after thoracotomy, which reduces the length of hospital stay, but chronic pain after thoracotomy (CPTP) still bother patients. CPTP may be caused by damage to the intercostal nerves result in significant neurological symptoms such as hyperalgesia and allodynia. Patients with abnormal sensations are estimated to last for months or even years, with an epidemiological incidence of up to 40%. This pain will affects functional activity and quality of life. Despite drug can partially suppress pain around surgical wound, but we want to explore a non-pharmaceutical intervention. In this study, we will evaluate whether treadmill exercise training reduces chronic post-thoracotomy pain in a rat model after thoracotomy. Methods: Male SD rats were distributed randomly into 5 groups: thoracotomy with rib retraction group (TRR) and TRR with treadmill exercise group (TRR-E), thoracotomy without rib retraction group (Sham), thoracotomy without rib retraction with exercise group (Sham-E), and control group. After thoracotomy procedure, the rats were trained to run for 6 weeks. Pain-related behavioural test was measured and the threshold was being record by Von-Frey filaments or acetone. Result: On day 10 after thoracotomy, rats exhibited a marked and continued hypersensitivity to von Frey tactile and cold stimuli. The threshold of TRR and TRR-E group were significant decrease compared with control group (P < 0.05), but there are similar within Sham and sham-E group. Mechanical withdrawal thresholds were increased compared with TRR (P < 0.05) following 35 days of treadmill intervention, but thresholds remained lower than control rats; moreover, cold allodynia was also reversed on 35 days in TRR-E group (P < 0.05). The threshold was not obvious different within other 3 groups in the experiment. After thoracotomy, rats demonstrated higher IL-1βand TNF-αexpression than control group, and showed decrease trend after 6 weeks treadmill intervention. Conclusion: We concluded that forced treadmill running alleviated chronic post-thoracotomy pain. This appear provide an effective way for patients in clinical, it''s helpful about their pain management and life quality.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Master of Science in Physiotherapy Johannesburg, 2015
Physiotherapy treatment is an essential component in the management of patients after open thoracic surgery in order to prevent respiratory complications and improve shoulder and thoracic cage mobility (Reeve, 2008). To date, limited research has been done on patients who have had open thoracotomy surgery. The body of knowledge and evidence on physiotherapy management of thoracotomy patients need to be addressed. The aim of this research report was to establish which physiotherapy treatment modalities are used in the management of thoracotomy patients in Gauteng. Methods: A self-administered questionnaire was used to obtain the data for this descriptive, cross sectional study. A sample of convenience was used and questionnaires were distributed to all physiotherapists registered with the SASP (South African Society of Physiotherapy) in Gauteng. Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics committee. An expert panel established the content validity of the questionnaire. The provisional questionnaire was piloted electronically via survey monkey. Invitations for participation in the main study were sent out after amendments were made to the questionnaire following the pilot study. Data for the main study was collected over a period of two months. Results: The questionnaire was distributed to 1389 physiotherapists registered with the SASP in Gauteng. Three hundred and twenty three physiotherapists (23.3%) responded. Only 141 of the responders were eligible for inclusion in the study. Ninety-five respondents indicated that they only see thoracotomy patients while still in hospital, 25 said they see these patients only after discharge while 21 respondents treated these patients both during and after hospital stay. The majority of physiotherapists who treat thoracotomy patients were females between the ages of 23 to 69. Results indicated that pre-operative physiotherapy management was most commonly determined by the patients’ risk profiles and consisted of information and respiratory techniques. Prophylactic post-operative management was high and in accordance with studies from Reeve et al (2007) and Agostini et al (2013). The modalities used most commonly were respiratory techniques with deep breathing exercise (97.6%: n=83), coughing (95.3%; n=81) and ACBT (82.4%: n=70), scoring highest. Exercise interventions used were early mobilistation (95.3%; n=81), trunk- (85.9; n=73) and upper limb mobility exercises (91.8%; n=78). Limited modalities focused on treating pain with OMT (11.8%; n=10) and transcutaneous electrical nerve stimulation (12.9%; n=11), being the modalities of choice. Post-hospital discharge physiotherapy management was uncommon with only 32.6% (n=46) of respondents treating patients during this phase. During the first six weeks after discharge the main focus of treatment was on respiratory difficulties (64%; n=41). After six weeks the focus moved to treating pain (57.8%; n=37). Management choices during all phases of contact with patients undergoing open thoracotomies were influenced by personal experience and established practice protocols as mentioned in the questionnaire. Conclusion: High quality evidence regarding the management of patients after open thoracic surgery still seems to be limited when compared to other high risk surgery groups (Reeve, 2008). Considering this, it seems that physiotherapists in Gauteng are using the relevant techniques to prevent and manage postoperative pulmonary complications (PPCs) in patients that undergo open thoracic surgery. Pre- and post-operative techniques most commonly used were respiratory techniques and early mobilisation. Management choices seem to be predominantly affected by experience and established practice protocol. There is a lack in pain management for these patients both during and after hospital stay.

Various techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which technique or drug regime is best. We have systematically reviewed the efficacy and safety of different techniques for PVB. Our primary aim was to determine whether local anaesthetic (LA) dose influences the quality of analgesia from PVB. Secondary aims were to determine whether choice of LA agent, continuous infusion, adjuvants, pre-emptive PVB, or addition of patient-controlled opioids improve analgesia. Indirect comparisons between treatment arms of different trials were made using metaregression. Twenty-five trials suitable for metaregression were identified, with a total of 763 patients. The use of higher doses of bupivacaine (890¿990 mg per 24 h compared with 325¿472.5 mg per 24 h) was found to predict lower pain scores at all time points up to 48 h after operation (P=0.006 at 8 h, P=0.001 at 24 h, and P<0.001 at 48 h). The effect-size estimates amount to around a 50% decrease in postoperative pain scores. Higher dose bupivacaine PVB was also predictive of faster recovery of pulmonary function by 72 h (effect-size estimate 20.1% more improvement in FEV1, 95% CI 2.08%¿38.07%, P=0.029). Continuous infusions of LA predicted lower pain scores compared with intermittent boluses (P=0.04 at 8 h, P=0.003 at 24 h, and P<0.001 at 48 h). The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. Further well-designed trials of different PVB dosage and drug regimes are needed.

PURPOSE: Hemothorax, the collection of blood in the intrapleural space, commonly arises in patients suffering from thoracic trauma. Fluid collections in this space can compromise cardiac and respiratory function and if left untreated, can result in hypovolemic crisis. Fluid is often successfully drained via a tube thoracostomy, in which an intercostal drain is inserted into the pleural space. If residual blood remains, however, clotting may occur and result in a retained hemothorax (RH). Intrapleural administration of tissue plasminogen activator (tPA), a fibrinolytic drug typically utilized in ischemic stroke, has been shown to be both a safe and effective technique to hydrolyze RH clots and reduce the need for more invasive surgical interventions. The present study aims to evaluate the safety and efficacy of tPA administration at Boston Medical Center (BMC) and compare this data to those of prior studies. This study will also investigate if tPA as a definitive treatment for RH, could reduce the need for additional interventions such as surgical procedures including Video-Assisted Thoracoscopic Surgery (VATS) and/or invasive thoracaotomy. Hospital/intensive care unit (ICU) lengths of stay (LOS), ventilator time, and complication rates will be used to determine if tPA may allow for a significant decrease in patient cost and burden of care versus surgery. An analysis of patient demographics and injury data will be used to determine the individual factors that could be used to predict the success of tPA as a definitive treatment. Using evidence-based treatment protocols, the aforementioned data will be critically evaluated to determine the appropriate timing and sequential positioning of tPA administration in the treatment algorithm for retained hemothorax. METHODS: A single-institution retrospective chart review was conducted of patients treated for traumatic pneumohemothorax by the Department of Acute Care and Trauma Surgery at Boston Medical Center. A study on predictive factors of the development of retained hemothorax included all such patients that presented to the emergency department (ED) between May 2014 and June 2016. Demographic and injury characteristics were analyzed to determine if patients from specific groups or with specific injuries are more prone to develop RH. To evaluate the safety of intrapleural tissue plasminogen activator, the incidence of complications such as post-trauma infection and mortality were determined in patients that were administered tPA to resolve retained hemothorax between May 2014 through December 2016. Next, utilizing an expanded data set, the efficacy of tPA was evaluated by determining the percentage of cases in which tPA was able to definitively resolve RH. Secondary efficacy data including average hospital length of stay, average ICU length of stay, average mechanical ventilation time, and rate of readmission were compared between various interventions as well. Finally, to elucidate the risk factors for RH and independent predictors of tPA as a definitive treatment, demographic data including age, ethnicity, and gender as well as injury data including mechanism of injury, the presence or absence of multisystem trauma, and the presence or absence of specific injuries such as rib fracture, pulmonary contusion, or diaphragmic insult were collected. RESULTS: A statistically significant positive correlation was observed between the likelihood of developing RH and both abdominal alimentary tract and extremity injuries, indicating that these injuries may serve as predictive factors for RH development. In a study investigating the safety of intrapleural tPA, there was no statistically significant difference in post-trauma infection rates between individuals treated with tPA and those who were not. Additionally, tPA treatment was associated with a lower mortality rate. Efficacy studies revealed that tPA therapy was associated with a statistically significant decrease in mechanical ventilation time, as compared to surgical intervention, however, tPA carried a RH resolution rate of just 43% with one patient experiencing a major adverse systemic reaction to the drug. Finally, demographic and injury data were analyzed to determine predictive factors of tPA success, but no statistically significant relationships were observed between any of these characteristics and the outcome of tPA therapy. CONCLUSION: Intrapleural tPA is a safe and effective alternative to more invasive surgical procedures. The success rate of tPA therapy in the present study was less than previous studies have indicated, however, the potential decreased ventilation time is important for preventing ventilator associated pneumonia (VAP) and the high rate of mortality it carries. Although the success rate is lower than expected, tPA should still be considered in the RH treatment protocol, prior to surgery, to decrease required ventilation time and potentially prevent the need for more invasive interventions with higher costs, morbidity, mortality rates, and patient burden.

Thesis (M.N.)--University of Alberta, 2010.
A thesis submitted to the Faculty of Graduate Studies and Research in partial fulfillment of the requirements for the degree of Master of Nursing, Faculty of Nursing. Title from pdf file main screen (viewed on April 22, 2010). Includes bibliographical references.