Persistent postsurgical pain: the path forward through better design of clinical studies. Impact of Pregabalin on the Occurrence of Postthoracotomy Pain Syndrome: A Randomized Trial European Respiratory Society guidelines for the management of adult bronchiectasis The role of video-assisted thoracic surgery for the treatment of lung cancer: lung lobectomy by thoracoscopy versus the standard thoracotomy approach. The effect of pre-emptive intravenous Dexketoprofen + thoracal epidural analgesia on the chronic post-thoracotomy pain. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Lobectomy--video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. A questionnaire study investigating the prevalence of the neuropathic component of chronic pain after thoracic surgery. Co-analgesic effect of ketorolac after thoracic surgery. Analgesia in post-thoracotomy patients: Comparison between thoracic epidural and thoracic paravertebral blocks Has postoperative pain been eradicated? The future of fast‐track surgery A study exploring the role of intercostal nerve damage in chronic pain after thoracic surgery. Control of postoperative pain by transcutaneous electrical nerve stimulation after thoracic operations. Preoperative education and use of analgesic before onset of pain routinely for post-thoracotomy pain control can reduce pain effect and total amount of analgesics administered postoperatively. Pre-emptive effect of multimodal analgesia in thoracic surgery. Continued disability and pain after lumbar disc surgery: The role of cognitive-behavioral factors Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Palliative surgical debulking in malignant mesothelioma. Predictors of survival and symptom control. Is there any benefit to adding intravenous ketamine to patient-controlled epidural analgesia after thoracic surgery? A randomized double-blind study. Lobectomy by video-assisted thoracic surgery (VATS) versus thoracotomy for lung cancer. Perioperative metoprolol reduces the frequency of atrial fibrillation after thoracotomy for lung resection. Comparison of epidural analgesia and intercostal nerve cryoanalgesia for post‐thoracotomy pain control
CHRONIC pain continues to be a major humanitarian and socioeconomic burden with slow progress in the development of new preventive and therapeutic options .  Persistent postsurgical pain ( PPP  ) is a well-known and common clinical entity with a reported incidence between 5 and 50 % of patients after various common operations . PPP has received increased interest during the past 10–15 yr . These patients can be studied before injury is inflicted , and thus , PPP provides a special opportunity to underst and pathogenic mechanisms for developing a chronic pain state or the transition from an acute to a chronic pain state . What have we learned from clinical trials regarding pathogenic mechanisms of PPP and the effects of preventive or therapeutic interventions ? Despite the increased attention to PPP , most studies have done little more than codify the striking frequency with which this problem occurs after many disparate types of surgery : from inguinal herniorrhaphy to thoracotomy to breast surgery . It is likely that the pathogenic mechanisms leading to PPP are multiple , and thus , more rigorous study design will be required to better underst and how the problem evolves and who is at greatest risk . Such careful study design has been the exception rather than the rule . What we do know is that those that seem to be most relevant are gender , psychosocial factors , preoperative pain at the site of surgery or in other body regions , the type of surgical trauma , nerve damage , acute postoperative pain and inflammatory responses , perioperative analgesia , type of disease , recurrence of malignancy , and adjuvant therapy . Several years ago , the International Association for the Study of Pain defined PPP as a persistent pain state that is apparent more than 2 months postoperatively that can not be explained by other causes ( recurrence of disease , inflammation , and others ) . Most of the available literature has followed the lead of this overly simplistic definition and is composed of reports with insufficient pain assessment and little information regarding its consequences . Too often , studies on PPP have been conducted using a single assessment , asking patients simply to report whether they have persistent pain at one point in time using only a simple yes or no answer . Future studies should include not only a detailed assessment of the location , characteristics , and evolution of painful symptoms and associated changes in neurologic function but also assessment s of the consequences of persistent pain on physical and social function . These studies must be performed on a procedure-specific basis because the type of surgery has different consequences on specific organ functions , and new assessment scales must be developed and vali date d for individual procedures . We have only limited information from vali date d procedure-specific scoring systems , the most comprehensive example being the post groin hernia surgery pain scale . Finally , previous classifications of PPP as neuropathic and nociceptive pain have lacked specific objective criteria for such subgroupings , leading to the artificial concept that these two types of pain can be easily teased apart — even more damaging is the concept that the treatment for these two interwoven pain syndromes somehow differs . Indeed , many patients with PPP report both sensory abnormalities and localized stimulus-evoked pain , suggesting that both abnormal nerve function and ongoing nociception play a role in PPP . Less than a h and ful of studies have included detailed neurophysiologic assessment of PPP . There is a dramatic need for similar procedure-specific studies that are conducted prospect ively to detail the evolution and characteristics of PPP and include pain-related functional impairment scales to assess the real impact of this problem . The pathogenic factors involved in PPP may be divided into patient and surgery-related factors , of which preoperative factors to be assessed in detail include psychosocial factors , pain and its consequences , nociceptive function , and gender . Of the intraoperative factors , type of anesthesia , surgical approach ( magnitude of tissue damage ) , nerve identification , and nerve injury are obviously important , and postoperative factors should include a detailed description of the type of analgesia , duration , early follow-up with neurophysiologic assessment s , disease data , and detailed assessment of pain and its functional consequences . Although 2 months postoperatively has been proposed as a criterion for PPP , the definition was not based on procedure-specific data , and after some operations , a continuous inflammatory response may be apparent calling for assessment s for at least 3–6 months postoperatively to provide useful information . Although these requirements for study design may seem obvious and easy to include in clinical trials , an example from a Accepted for publication November 17 , 2009 . The authors are not supported by , nor maintain any financial interest in , any commercial activity that may be associated with the topic of this article Background  Postthoracotomy pain syndrome ( PTPS )  is a frequent cause of chronic postoperative pain .  Pregabalin might reduce the incidence of chronic postoperative pain . The goal of this study was to evaluate the impact of perioperative pregabalin on the occurrence of PTPS , defined as any surgical site pain 3 months after surgery . Methods We conducted a r and omized , placebo-controlled , double-blind trial in patients undergoing elective thoracotomy . Patients received either pregabalin 150 mg orally twice a day initiated 1 hour before thoracotomy and continued until 4 days after thoracotomy ( 10 doses total ) or a placebo using the same protocol . All patients received preincision thoracic epidural analgesia .  Postthoracotomy pain syndrome was evaluated using the Brief Pain Inventory question naire through a telephone interview . Secondary outcomes included evaluation of neuropathic characteristics through the Leeds Assessment of Neuropathic Symptoms and Signs question naire , analgesic use 3 months after surgery , and evaluation of acute postoperative pain and opioid consumption . Results One hundred fourteen patients were r and omized , and 99 patients completed the study ( placebo , n = 49 ; pregabalin , n = 50 ) . Postthoracotomy pain syndrome occurred in 49 ( 49.5 % ) of 99 patients and more frequently in the pregabalin group ( 31/50 [ 62 % ] vs 18/49 [ 37 % ] in the placebo group , P = 0.01 ) . However , among patients with PTPS , those in the pregabalin group required significantly less analgesics , reported less moderate to severe average pain , and presented significantly less neuropathic characteristics than patients in the placebo group 3 months after surgery . Conclusions Pregabalin did not reduce the incidence of PTPS in this study . Future research on PTPS should focus on the impact of regional analgesia on central sensitization Bronchiectasis in adults is a chronic disorder associated with poor quality of life and frequent exacerbations in many patients . There have been no previous international guidelines . The European Respiratory Society guidelines for the management of adult bronchiectasis describe the appropriate investigation and treatment strategies determined by a systematic review of the literature . A multidisciplinary group representing respiratory medicine , microbiology , physiotherapy , thoracic surgery , primary care , methodology and patients considered the most relevant clinical questions ( for both clinicians and patients ) related to management of bronchiectasis . Nine key clinical questions were generated and a systematic review was conducted to identify published systematic review s , r and omised clinical trials and observational studies that answered these questions . We used the GRADE approach to define the quality of the evidence and the level of recommendations . The result ing guideline addresses the investigation of underlying causes of bronchiectasis , treatment of exacerbations , pathogen eradication , long term antibiotic treatment , anti-inflammatories , mucoactive drugs , bronchodilators , surgical treatment and respiratory physiotherapy . These recommendations can be used to benchmark quality of care for people with bronchiectasis across Europe and to improve outcomes . The publication of the first ERS guidelines for bronchiectasis Our objective was to evaluate the usefulness , safety , validity and benefits of video-assisted thoracoscopic surgery ( VATS ) for performing pulmonary lobectomy in 24 patients with clinical NO stage I primary non-small-cell lung cancer compared with 30 patients who underwent a conventional thoracotomy .  There were no significant differences in the intra-operative blood loss , duration of operation , or duration of chest tube drainage between the VATS group and the st and ard lobectomy group , but in this VATS ' experience , patients had less postoperative pain . Numbers and distributions of dissected lymph-nodes were similar in patients whether undergoing st and ard thoracotomy or VATS lobectomy . We can confirm that the safety and validity of VATS are virtually identical to those of the st and ard thoracotomy approach in the lobectomy . However , the former technique causes less discomfort to patients and requires a shorter recovery period of laboratory data and IL-6 concentrations in thoracic drainage fluid . We conclude that VATS major lung resection is technically feasible . Stringent patient selection is important and special training is needed Post thoracotomy chronic pain is a severe problem that affects the majority of patients and decreases the quality of life . The purpose of this study is to evaluate the long-term effects of thoracal epidural levobupivacaine and intravenous dexketoprofen analgesia formed pre-emptively on the wound site pain after major thoracotomy operations . This r and omised , prospect i ve and double-blind study was performed with 60 patients undergoing thoracic surgery . Patients were divided into three groups ; Control Group ( Group C ) , Pre-emptive Epidural Group ( Group PE ) and Pre-emptive Dexketoprofen + Epidural Group ( Group PED ) . Patients in the Group C did not receive epidural analgesics and i.v . dexketoprofen before and during the operation . 10 - 15 ml 0.125 % levobupivacaine was given to cases in Group PE pre-emptively through epidural catheter before the anesthesia induction . The cases in Group PED were given 10 - 15 ml 0.125 % epidural levobupivacaine and 50 mg dexketoprofen with i.v . infusion pre-emptively . The VAS score was found to be lower in Group PED during postoperative 24 and 48 hours and before the discharge ( P<0.05 ) . The VAS score was similar in all groups during the first and third months ( P>0.05 ) . A statistically significant decrease was determined in the VAS score in Group PED during the sixth month , compared to the other groups ( P<0.05 ) . When the scores of Patient Satisfaction Scale ( PSS ) of the cases were compared , they were found to be higher in Group PED as statistically significant during the discharge period ( P<0.001 ) . Scores of PSS were higher in Group PED as statistically significant during the postoperative month 6 ( P = 0.008 ) . Combined application of pre-emptive intravenous dexketoprofen and thoracal epidural analgesia reduce the chronic post-thoracotomy pain OBJECTIVES Despite advantages regarding pain and muscle function , video-assisted thoracic surgery ( VATS ) lobectomy is infrequently performed and is particularly controversial in bronchogenic carcinoma . We have , therefore , review ed our experience with VATS lobectomy for non-small cell lung cancer ( NSCLC ) in an attempt to define the long-term results of VATS lobectomy in this setting . METHODS Patients were selected for surgery on the basis of clinical Stage I or II disease with routine use of thoracic/upper abdominal CT scanning and cervical mediastinoscopy .  VATS resection was performed using the endoscopic hilar dissection technique . All related hilar nodes were cleared and supportative sampling of mediastinal stations beyond the reach of mediastinoscopy was undertaken . Perioperative data were collected prospect ively and oncologic outcomes were assessed by 6 monthly census . RESULTS One hundred and fifty eight patients ( mean age 66 years ) underwent 159 VATS lobectomies for NSCLC between May 1992 and December 2001 . One patient underwent staged bilateral resections . Twenty further procedures were uneventfully converted to open thoracotomy ( rate=11.2 % ) . The median operation time was 130 min and median operative blood loss was 60 ml . The median postoperative stay was 6 days . One patient ( 0.6 % ) died following VATS resection from acute respiratory distress syndrome ( ARDS ) . Two VATS resection patients died following discharge but within 30 days of surgery . Combined , inpatient and 30-day outpatient mortality was , therefore , 1.8 % . The stage distribution for resected lesions was : Stage I , 117 ; II , 33 and III , 8 . Mean follow-up was 38 months ( range : 1 - 107 ) . Tumour recurred in 36 patients presenting as local recurrence in the hilum or mediastinum in nine ( 25 % ) , metastatic disease in 23 ( 63.9 % ) and unknown pattern in four ( 11.1 % ) . Kaplan-Meier calculated probabilities of freedom from cancer related or associated death at 60 months were Stage I , 77.9 % ; II , 51.4 % and III , 28.6 % . CONCLUSION VATS lobectomy is a safe procedure which is associated with a low probability for conversion to open thoracotomy . The patterns of cancer recurrence do not suggest inadequate local clearance while the long-term survival data for Stage I NSLC cases is encouraging . We believe that this technique should become the operation of choice for early stage NSCLC Video-assisted thoracic surgery has been adopted by some thoracic surgeons as the preferred approach over thoracotomy for many benign and malignant diseases of the chest . However , little concrete evidence exists to support this technique as the superior approach . This r and omized study was carried out to define the advantages of video-assisted lobectomy over muscle-sparing thoracotomy and lobectomy .  Sixty-one patients with presumed clinical stage I non-small-cell lung cancer were entered into the study . Each patient was r and omized to muscle-sparing thoracotomy and lobectomy or video-assisted lobectomy .  Six patients were excluded from the study either because final pathologic results revealed nonmalignant disease ( 3 patients ) or because an attempted video-assisted lobectomy was converted to a thoracotomy . This left 30 patients in the thoracotomy group and 25 patients in the video-assisted group . No significant differences existed between the two groups in operating time , intraoperative blood loss , duration of chest tube drainage , or length of hospital stay . Significantly more postoperative complications occurred in the thoracotomy group ( p < 0.5 ) , the majority of which were prolonged air leaks . Return to work time was not an issue because the majority of the patients were either retired or not working at the time of the operation . Only three patients had persistent postthoracotomy pain ( thoracotomy , n = 2 ; video-assisted lobectomy , n = 1 ) . We conclude that video-assisted lobectomy was not associated with a significant decrease in duration of chest tube drainage , length of hospital stay , postthoracotomy pain , or , in this group of patients , a faster recovery time and return to work .  Video-assisted lobectomy continues to expose the patient to the risk of a major pulmonary resection being done in an essentially closed chest . These results illustrate the need for critical evaluation of video-assisted thoracic surgery before the procedure is accepted as a superior approach based on presumed and thus far unproved advantages OBJECTIVE Our question naire study set out to assess the prevalence of chronic pain after thoracic surgery , the contribution of the neuropathic component of chronic pain and the impact of chronic pain on patients ' lives . METHODS A question naire was sent to 1152 patients who had undergone thoracic surgery in our department between 7 months and 7 years ago . The question naire was design ed specifically for the study and included questions on neuropathic symptoms . Responses were correlated with data from our prospect ively entered data base for analysis . RESULTS Nine hundred and forty-eight people were included in the study , of which 600 responded ( 63 % ) . Prevalence of chronic pain is 57 % at 7 - 12 months , 36 % at 4 - 5 years and 21 % at 6 - 7 years . Patient age , consultant and time since the operation all have significant effects . Surgical approach ( video-assisted thoracoscopic surgery , thoracotomy ) and diagnosis are not significant . Thirty-nine percent of those with pain take analgesia , 46 % felt their pain is their worst medical problem and 40 % reported it limits their daily activities . The prevalence of each neuropathic symptom is between 35 and 83 % . The presence of a neuropathic symptom is associated with significantly more severe pain , more analgesia use and pain more likely to limit daily activity . CONCLUSIONS Chronic pain has a significant prevalence and impact on patients ' lives for several years after thoracic surgery . Nerve dysfunction is associated with more severe pain , a greater impact and tends to persist . The reason for the individual consultant being an important factor in post-thoracotomy pain needs further investigation Thoracotomies are painful surgical procedures and adequate pain relief is associated with improved respiratory function and fewer respiratory complications . After thoracotomy for lung resection , patients received morphine-based patient-controlled analgesia ( PCA ) . Three groups were prospect ively and r and omised investigated : patients receiving preemptive ketorolac , those given postoperative ketorolac and controls .  No differences among groups were found for demographic data , anaesthesia and surgery duration s , or for the amounts of anaesthesia drugs administered . The blood losses were also comparable : 565 + /- 374 ml for the preemptive ketorolac group . 749 + /- 491 ml for the postoperative ketorolac group and 674 + /- 323 ml for the controls . At 48 h after surgery , compared to controls , morphine consumption was 36 % lower for the preemptive ketorolac group and 17 % lower for postoperative ketorolac group ( p < 0.05 ) . No statistically significant differences were observed for pulmonary function tests . These results suggest that non-steroidal anti-inflammatory drugs can reduce the opioid requirements after thoracic surgery but do not improve lung function Background : Acute postoperative pain can cause detrimental effects on multiple organ systems , leading to chronic pain syndromes . Objective : To compare thoracic epidural block ( TEB ) and paravertebral block ( PVB ) for relief of postoperative pain in adult patients undergoing thoracotomy .  Material s and Methods : In this r and omized , single-blinded , prospect i ve study , 60 adult patients of both sexes , belonging to ASA physical status I and II , were scheduled for elective thoracotomy under general anesthesia .  They were r and omly divided into two groups , A and B of 30 each , who were comparable in terms of demographic parameters and body weight . Group A received TEB and Group B received PVB . All the patients underwent thoracotomy under general anesthesia using a uniform st and ard anesthetic technique . Thirty minutes before the anticipated end of skin suture , blocks were activated in both the groups with 7.5 ml for TEB and 15 ml for thoracic PVB of 0.25 % bupivacaine , along with 1 ml of fentanyl for postoperative analgesia . Results : Patients receiving PVB for postoperative analgesia experienced better analgesia than those receiving TEB from the immediate postoperative period that lasted longer . Intragroup comparison showed that in the cases receiving TEB , there was a significant statistical difference in preoperative and postoperative values with regard to the mean systolic blood pressure ( SBP ) , mean arterial pressure and mean pulse rate . However , in patients receiving PVB , significant difference in preoperative and postoperative values was seen in mean SBP only . Conclusions : We observed longer duration of analgesia with PVB compared to TEB Recent evidence suggests that surgical trauma induces a process of central nervous system sensitisation that contributes to and enhances postoperative pain . These changes are also thought to be the underlying cause of much chronic pain . Central sensitisation is generated not only during surgery , but also postoperatively as a result of the inflammatory response to the damaged tissue . This knowledge provides a rational basis for pro-active , pre-emptive and postoperative analgesic strategies to reduce the neuronal barrage associated with tissue damage . Reduction or elimination of postoperative pain is therefore possible . We advocate the use of continuous extrapleural intercostal nerve block for postoperative analgesia in patients undergoing thoracotomy .  When this is begun pre-emptively ( by precutaneous , pre-incisional paravertebral block ) it is combined with an opiate and a non-steroidal anti-inflammatory drug premedication . In a r and omised study of 56 patients , pain scores of less than 0.5 cm on a 10 cm scale were produced , postoperative lung function was preserved and glucose and cortisol responses were significantly unchanged from preoperative values . Evidence that effective perioperative analgesia reduces the incidence of chronic post-thoracotomy chest wall pain was found in a retrospective study of 1000 consecutive thoracotomies . The endpoints of a zero pain score , complete preservation of preoperative lung function and prevention of the stress response to trauma are currently achievable and should be provided for virtually all patients undergoing chest surgery . Pre-empting pain must be the goal for all those involved in the postoperative care of patients Since its introduction in the 1990s , the concept of multimodal perioperative care ( fast-track surgery , enhanced recovery programmes ) has gained widespread acceptance and is now considered as a st and ard of care . Most studies that support this approach relate to colorectal surgery , but similar data have been published across surgical specialties with major economic benefits 1–4 . The implementation process has been described in detail and is essentially based on the simple question : ‘ Why is the postoperative patient in hospital today?’1,5 . The relevant question may therefore be asked – what next ? Postoperative length of stay is often seen as the key outcome for fast-track surgery and , although this may not always be appropriate , whatever is used as a primary outcome measure must be justified adequately . It should also be emphasized that significant progress in fast-track care dem and s inclusion and implementation of all of its basic components . Many studies have not implemented the most important aspects of the care programmes that were originally described , including patient information , effective thoracic epidural analgesia with sufficient local anaesthetic that facilitates early mobilization , reduced ileus and rapid re introduction of oral feeding , or the use of non-opioid analgesia , where appropriate , in open or minimally invasive surgery . An important issue that needs to be addressed in future is detailed analysis of ‘ medical ’ versus ‘ surgical ’ morbidity6 . To improve further our underst and ing of perioperative risk , future studies must analyse how one specific complication might lead to another : for instance , whether a pneumonia or myocardial infa rct ion led to an anastomotic dehiscence ; or a wound dehiscence with reoperation led to a subsequent pneumonia , myocardial infa rct ion or thromboembolic complication6 . Initial ‘ medical ’ morbidity may depend on perioperative care principles and pre-existing comorbidity , in contrast to an initial ‘ surgical ’ complication , which may depend on surgical technique , and therefore require a different approach from fast-track methodology . How might the fast-track approach evolve further , as surgeons perform an ever-increasing number of major procedures in older patients with comorbidities , with greater risks of postoperative complications , prolonged hospital stay and death6 ? Preoperative evaluation of operative risk may not be helpful unless evidence -based perioperative interventions are available and instituted . Thus , the specific role of preoperative morbidity , such as smoking , diabetes and cardiopulmonary disease , in determining the risk of postoperative morbidity needs to be reassessed in studies with a fully implemented fast-track procedure-specific programme6 . We also need to have a second look at the relative roles of the different components of the fast-track programme ( for example type of analgesia and fluid management1,5 ) and analyse where progress can be made in order to reduce perioperative risk and morbidity , instead of focusing on length of stay as the primary outcome . The surgical stress response is proportional to the degree of insult and the main factor that contributes to postoperative organ dysfunction1,2 . Every effort should therefore be made to reduce those responses that are undesirable . Regional anaesthetic techniques have a powerful effect on the catabolic response , reducing cardiac dem and s , pain , pulmonary dysfunction and ileus .  Regional anaesthesia should be used whenever possible on a procedure-specific basis7 . Inflammatory responses contribute to pain , fatigue and organ dysfunction . They can be modified pharmacologically by preoperative glucocorticoids8 . Significant reductions in pain , nausea and vomiting , and early fatigue have been demonstrated , facilitating early recovery , so far without demonstrable side-effects . More procedure-specific and dosefinding studies are required . A single preoperative glucocorticoid dose in a larger amount than used for conventional nausea and vomiting prophylaxis might , for instance , be an important contributory factor to improving fast-track programmes in high-risk patients . Minimally invasive surgery also reduces the inflammatory response , although the contribution that this plays in the context of fast-track programmes in colonic surgery is difficult to interpret , as the care programmes used in the ‘ open ’ groups have often not been fully implemented6,9,10 . Therefore , future efforts to assess early postoperative outcome effects of minimally invasive surgery should include r and omized studies with fully implemented fasttrack programmes11 . Newer developments in minimally invasive OBJECTIVE Our aim was to investigate the prevalence of intra-operative nerve damage and its association with  chronic pain .  METHODS Our prospect i ve study of 33 patients used nerve conduction studies to assess intercostal nerve function during elective thoracic surgical procedures . We used two methods to study nerve conduction : pre-operative magnetic stimulation ( in 10 patients ) and intra-operative nerve conduction studies ( in all patients ) We correlated these findings with specific intra-operative parameters , pain and psychological question naires pre-op and 3 month post-op and altered cutaneous sensation . RESULTS Magstim ( magnetic stimulation ) assessment s were not reliable and were therefore ab and oned . Intraoperative intercostal nerve studies revealed two distinct patterns of nerve injury and also that nerve injury was less in those cases where a rib was not resected . However , intercostal nerve damage detected at the time of operation is not associated with chronic pain or altered cutaneous sensation at 3 months post-op . CONCLUSIONS The study findings suggest that either the amount of intra-operative intercostal nerve damage is not indicative of long-term nerve damage or that there is a more significant cause for chronic pain other than intercostal nerve injury BACKGROUND Transcutaneous electrical nerve stimulation ( TENS ) has been used extensively to control postoperative pain , but its effects are controversial . This is probably due to the different types of operations performed and , therefore , to the varying intensity of postoperative pain . Here we present an extensive study with TENS in 324 patients who underwent different types of thoracic surgical procedures : posterolateral thoracotomy , muscle-sparing thoracotomy , costotomy , sternotomy , and video-assisted thoracoscopy .  METHODS Each patient cohort was r and omly subdivided into three treatment groups : TENS , placebo TENS and control . The effectiveness of TENS was assessed by two factors : the time from the beginning of treatment to the request for further analgesia and the total medication intake during the first 12 hours after operation . RESULTS Whereas posterolateral thoracotomy produced severe pain , muscle-sparing thoracotomy , costotomy , and sternotomy caused moderate pain , and video-assisted thoracoscopy caused only mild pain . The TENS treatment was not effective in the posterolateral thoracotomy group , but it was useful as an adjunct to other medications in the muscle-sparing thoracotomy , costotomy , and sternotomy groups . In contrast , representing the only pain control treatment with no adjunct drugs , it was very effective in patients having video-assisted thoracoscopy . CONCLUSIONS These findings show that TENS is useful after thoracic surgical procedures only when postoperative pain is mild to moderate ; it is uneffective for severe pain The purpose of this study was to investigate the efficiency of preoperative pain management education and the role of analgesics administration before the onset of pain postoperatively . The study was a prospect i ve , r and omized , and single-blind clinical trial , which was conducted January 1 , 2008 through October 1 , 2008 in the Thoracic Surgery Unit of Akdeniz University Hospital . A total of 70 patients who underwent thoracotomy ( 35 in the control group and 35 in the study group ) were included in the study . Of the patients , 70 % ( n = 49 ) were male and 30 % ( n = 21 ) were female . Mean age was 51 ± 10 years ( range = 25 - 65 ) . The same analgesia method was used for all patients ; the same surgical team performed each operation . Methods , including preemptive analgesia and placement of pleural or thoracic catheter for using analgesics , that were likely to affect pain level , were not used . The same analgesia medication was used for both patient groups . But the study group , additionally , was educated on how to deal with pain preoperatively and on the pharmacological methods to be used after surgery . An intramuscular diclofenac Na 75 mg was administered to the study group regardless of whether or not they reported pain in the first two postoperative hours . The control group did not receive preoperative education , and analgesics were not administered to them unless they reported pain in the postoperative period . The routine analgesics protocol was as follows : diclofenac Na 75 mg ( once a day ) intramuscular administered upon the complaint of pain following extubation in the postoperative period and 20 mg mepederin intravenously ( maximum dose , 100 mg/day ) , in addition , when the patient expressed pain . Pain severity was assessed during the second , fourth , eighth , 16th , 24th , and 48th hours , and marked using the Verbal Category Scale and the Behavioral Pain Assessment Scale . Additionally , the total dose of daily analgesics was calculated . The demographic characteristics showed a homogeneous distribution in both patient groups .  The rate of pain , which was defined as sharp , stabbing , and exhausting , was higher in the control group than in the study group , and the difference between the two groups was statistically significant ( p < .05 ) . As the doses of analgesics used for pain management in both groups were compared , it was determined that analgesic consumption was lower in the study group than in the control group , and the difference was statistically significant ( p < .05 ) . As a result , it was determined that preoperative thoracic pain management education and analgesics administered postoperatively , before the onset of pain , reduced the amount of analgesics used in the first postoperative 48 hours Thirty subjects undergoing posterolateral thoracotomy were allocated r and omly to receive one of two analgesic regimens : group Pre received i.v . morphine , i.m . diclofenac and intercostal nerve blocks from T2 to T11 , 20 min before operation and placebo injections after operation . Group Post received placebo injections before operation , and i.v . morphine , i.m . diclofenac and intercostal nerve blocks from T2 to T11 at the end of surgery , before discontinuation of anaesthesia . Visual analogue pain scores , extent and duration of intercostal nerve block , analgesic consumption and complications were assessed during the postoperative period by a single blinded observer . Subjects were followed-up for a minimum of 12 months to determine the incidence of post-thoracotomy pain syndrome . During the first 48 h after operation there were lower pain scores in group Pre when taking a vital capacity breath but there were no significant differences between the groups in any other measure . The effects of pre-emptive analgesia given before surgery appeared to be relatively modest in terms of analgesia , analgesic consumption and long-term outcome and were of limited clinical significance Abstract Cognitive‐behavioral factors are considered important in the development of chronic disability and pain in patients with low back pain . In a prospect i ve cohort study of 277 patients undergoing surgery for lumbosacral radicular syndrome , the predictive value of preoperatively measured cognitive‐behavioral factors ( fear of movement/(re)injury , passive pain coping , and negative outcome expectancies ) for disability and pain intensity at 6 weeks and 6 months after surgery was investigated , taking into account the effect of possible confounding variables . Higher levels of cognitive‐behavioral factors were found to be associated with a worse outcome at both 6 weeks and 6 months . These associations remained significant after controlling for possible confounding variables ( preoperative disability and pain intensity , age , gender , educational level , duration of complaints , neurological deficits , and intake of analgesics ) and pain intensity 3 days postoperatively . In multiple regression analyses , the cognitive‐behavioral factors independently predicted different outcomes . Fear of movement/(re)injury predicted more disability and more severe pain at 6 weeks and more severe pain at 6 months ; passive pain‐coping strategies predicted more disability at 6 months ; and negative outcome expectancies predicted more disability and more severe pain at both 6 weeks and 6 months . The findings support the potential utility of preoperative screening measures that include cognitive‐behavioral factors for predicting surgical outcome , as well as studies to examine the potential benefits of cognitive‐behavioral treatment to improve surgical outcome OBJECTIVE Long-term pain is a common sequela of thoracotomy , occurring in approximately 50 % of patients 2 years after thoracic surgery . Despite this alarming statistic , little is known about the factors responsible for the transition of acute to chronic pain . The aim of the present study is to identify predictors of long-term post-thoracotomy pain . DESIGN Follow-up was for 1.5 years for patients who had participated in a prospect i ve , r and omized , controlled trial of preemptive , multimodal analgesia .  SETTING Subjects were recruited from a tertiary care center . PATIENTS Thirty patients who had undergone lateral thoracotomy  were followed up by telephone , administered a structured interview , and classified according to long-term pain status . MAIN OUTCOME MEASURES Present pain status was measured by a verbal rating scale ( VAS ) . Measures obtained within the first 48 h after surgery were compared between patients with and without pain 1.5 years later . These include VAS pain scores at rest and after movement , McGill Pain Question naire data , patient-controlled morphine consumption ( mg ) , and pain thresholds to pressure applied to a rib contralateral to the thoracotomy incision . RESULTS Fifty-two percent of patients reported long-term pain . Early postoperative pain was the only factor that significantly predicted long-term pain . Pain intensity 24 h after surgery , at rest , and after movement was significantly greater among patients who developed long-term pain compared with pain-free patients . A significant predictive relationship was also found at 24 and 48 h using the McGill Pain Question naire . Cumulative morphine was comparable for the two groups . Pain thresholds to pressure applied to a rib contralateral to the incision did not differ significantly between the groups . CONCLUSION Aggressive management of early postoperative pain may reduce the likelihood of long-term post-thoracotomy pain OBJECTIVE Malignant mesothelioma ( MM ) typically presents at an advanced stage . In the UK surgical intervention has been mostly reserved for tissue diagnosis or chemical pleurodesis . However , the role of debulking surgery in symptom control has not been fully explored . METHODS In a prospect i ve cohort study , 51 consecutive patients presenting with MM underwent palliative surgical debulking for symptomatic relief ( all patients presented with dyspnoea , 39 also had pain and two had a co-existing pleural empyema ) . Patients with early disease who underwent extrapleural pneumonectomy were excluded . The treatment aims were pleural drainage , lung re-expansion , pleurodesis and pleural debulking for symptom control . If the lung re-exp and ed after drainage of the effusion a subtotal parietal pleurectomy was performed via Video Assisted Thoracic Surgery ( VATS ) . If the lung remained entrapped , a parietal and visceral decortication using VATS or thoracotomy was performed . The changes in subjective dyspnoea and pain scores were recorded at 6 weeks and 3 , 6 and 12 months after surgery . Prognostic factors were analyzed to determine their influence on survival and symptom control . RESULTS  VATS pleurectomy  was possible in 17 patients ( 34 % ) , whilst decortication was required in the remainder ( three by VATS and 31 by thoracotomy ) . Median postoperative stay was 7 days ( range 2 - 17 ) with 30-day mortality of 7.8 % ( four of 51 patients ) . Morbidity included postoperative empyema in two patients ( 4 % ) and prolonged air-leak in five ( 9.8 % ) . Overall significant symptomatic benefit was obtained up to 3 months after surgery but subsequently increasing mortality offset these benefits . Epithelial cell type and absence of weight loss prior to surgery were found to predict longer survival and successful symptom control . CONCLUSIONS Debulking surgery has a beneficial role in symptom control for unresectable MM . However , this surgery should be reserved for those patients who present with epithelial cell type and before significant loss of weight OBJECTIVES Thoracic surgery is associated with severe acute postoperative pain , leading to pulmonary complications and hyperalgesia-induced chronic pain . Thoracic patient-controlled epidural analgesia is also considered as the gold-st and ard postoperative analgesia . As previously described in major digestive surgery , combination with low-dose intravenous ( i.v . ) ketamine could potentiate epidural analgesia and facilitate pulmonary function recovery following thoracotomy . METHODS In a r and omized , double-blind trial , 60 patients scheduled to undergo thoracotomy were included . All patients received a thoracic epidural catheter placed before surgery , and st and ardized general anaesthesia . They were allocated to two groups to receive either an i.v . bolus of ketamine at induction , followed by a continuous infusion during surgery and the first 48 h postoperatively , or an i.v . placebo ( a saline solution under the same infusion modalities ) . Cumulative epidural ropivacaine consumption , postoperative pain scores ( patient self-rated numeric pain intensity scale ) , analgesic rescue consumption , residual pain , haemodynamics and respiratory recovery function were recorded from 12 h to 3 months . Data were expressed as mean ± st and ard deviation or median ± interquartile range ( 25 - 75 % ) . The comparisons between ketamine and placebo groups were performed using χ(2 ) or Fisher 's exact tests for frequencies , and Mann-Whitney tests for quantitative variables . RESULTS Epidural ropivacaine consumption was similar between groups during the first 48 postoperative hours . Postoperative pain scores and spirometric parameters were not significantly different between groups . But the incidence of postoperative nausea was significantly increased in patients owning to the ketamine group . Finally , the incidence of residual pain was similar between groups at 1 and 3 months following thoracotomy . CONCLUSIONS Adding i.v . ketamine did not potentiate epidural analgesia neither to reduce acute and chronic postoperative pain nor to improve pulmonary dysfunction following thoracic surgery . Pain scores were low in both groups , mainly because of an optimized analgesia provided by the patient-controlled epidural mode , and might explain this lack of benefit in adding i.v . ketamine BACKGROUND The optimal surgical technique for lobectomy in lung cancer is not well defined . Proponents of video-assisted thoracic surgery ( VATS ) hypothesize that less trauma leads to quicker recovery , whereas those who advocate thoracotomy cl aim it as an oncologically superior procedure . However , a well-balanced comparison of the two procedures is lacking in the literature . METHODS All patients who underwent lobectomy for clinical stage 1A lung cancer by computed tomographic and positron emission tomographic scan were identified from a prospect i ve data base . Patient characteristics were compared by the Student t test , Pearson chi(2 ) , and Fisher exact test . A propensity score-matched analysis was performed . Survival was assessed by Kaplan-Meier and Cox proportional hazards analysis . Complications were assessed by a multivariate logistic regression model evaluating age , sex , comorbidities , pulmonary function , tumor size , nodal status , surgeon , and histologic characteristics . RESULTS From May 2002 to August 2007 , 398 patients underwent an attempt at VATS lobectomy and 343 underwent thoracotomy .  An " intent-to-treat " analysis was performed . There was 1 postoperative death in each group . Survival by Cox model was no different for VATS versus thoracotomy ( hazard ratio 0.72 ; P = .12 ) , whereas age ( hazard ratio 1.03 ; P < .001 ) , larger tumor size ( hazard ratio 1.34 ; P < .001 ) , and higher nodal stage ( hazard ratio 1.92 ; P < .001 ) were associated with worse survival . Logistic regression demonstrated fewer complications for VATS lobectomy ( odds ratio 0.73 ; P = .06 ) , whereas age ( odds ratio 1.04 ; P < .001 ) and tumor size ( odds ratio 1.2 ; P < .020 ) correlated with a greater number of complications . Patients undergoing VATS lobectomy demonstrated a 2-day shorter length of stay than patients undergoing thoracotomy ( P < .001 ) . Propensity score-matched analysis supported these findings . CONCLUSIONS VATS lobectomy and thoracotomy demonstrated similar 5-year survivals . However , VATS lobectomy was associated with fewer complications and shorter length of hospital stay OBJECTIVE The association of atrial fibrillation with thoracic surgical procedures is well known , but nevertheless its cause is not well defined . Increased sympathetic activity may play a role in the development of atrial fibrillation , and reduced beta-receptor activity may be advantageous . The objective was to evaluate the effect of oral beta-blockade on the frequency of atrial fibrillation and to evaluate some possible causative factors . DESIGN AND SETTING The study was prospect i ve , r and omized , and double-blind , and was conducted at Aarhus University Hospital . PARTICIPANTS Thirty patients without previous or present cardiovascular history undergoing elective thoracotomy for lung resection . INTERVENTIONS The patients received either 100 mg of metoprolol or placebo orally before surgery and once daily postoperatively . Anesthesia consisted of a thoracic epidural block combined with general intravenous anesthesia . Epidural morphine was continued postoperatively . MEASUREMENTS AND MAIN RESULTS Patients were monitored with electrocardiograms ( ECGs ) , capillary pulse oximetry , invasive hemodynamic monitoring , central venous oxygen saturation , arterial blood gases , serum electrolytes , and fluid balances . Atrial fibrillation developed in 23.3 % of the patients , 6.7 % after metoprolol compared with 40 % in the placebo group . Atrial fibrillation developed a mean of 2.9 days postoperatively . The predominant hemodynamic findings were perioperative lower oxygen consumption and postoperative lower cardiac index after metoprolol . Patients developing atrial fibrillation had much higher oxygen consumption and postoperative cardiac index than other patients . CONCLUSION Perioperative oral beta-blockade can reduce the frequency of atrial fibrillation without serious side effects . Increased sympathetic activity is one of the predominant factors in the cause of this complication Epidural analgesia is regarded as the gold method for controlling post‐thoracotomy pain . Intercostal nerve cryoanalgesia can also produce satisfactory analgesic effects , but is suspected to increase the incidence of chronic pain . However , r and omized controlled trials comparing these two methods for post‐thoracotomy acute pain analgesic effects and chronic pain incidents have not been conducted previously . We studied 107 adult patients , allocated r and omly to thoracic epidural bupivacaine and morphine or intercostal nerve cryoanalgesia .  Acute pain scores and opioid‐related side effects were evaluated for three postoperative days . Chronic pain information , including the incidence , severity , and allodynia‐like pain , was acquired on the first , third , sixth and twelfth months postoperatively . There was no significant difference on numeral rating scales ( NRS ) at rest or on motion between the two groups during the three postoperative days . The patient satisfaction results were also similar between the groups . The side effects , especially mild pruritus , were reported more often in the epidural group . Both groups showed high incidence of chronic pain ( 42.1–72.1 % ) , and no significance between the groups . The incidence of allodynia‐like pain reported in cryo group was higher than that in Epidural group on any postoperative month , with significance on the sixth and the twelfth months postoperatively ( P<0.05 ) . More patients rated their chronic pain intensity on moderate and severe in cryo group and interfered with daily life ( P<0.05 ) . Both thoracic epidural analgesia and intercostal nerve cryoanalgesia showed satisfactory analgesia for post‐thoracotomy acute pain . The incidence of post‐thoracotomy chronic pain is high . Cryoanalgesia may be a factor that increases the incidence of neuropathic pain
However , intercostal nerve injury seems to be the most important pathogenic factor .
Chronic pain complaints after thoracic surgery represent a significant clinical problem in 25 - 60 % of patients .
Results from thoracic and other surgical procedures suggest multiple pathogenic mechanisms that include pre- , intra- , and postoperative factors .
This review attempts to analyse the methodology and systematic s of the studies on the  post-thoracotomy pain syndrome ( PTPS ) after lung cancer surgery in adults , in order to clarify the relative role of possible pathogenic factors and to define future strategies for prevention .