**5. Patient care managment**

The use of bronchodilators, corticosteroids or a combination of both, as well as pulmonary rehabilitation and smoking cessation can help reduce postoperative complications occurring after thoracic surgery, especially in patients with comorbidities who present declining values of FEV1 or DLCO.

#### **5.1 Smoking cessation**

Smokers have significantly higher risk of postoperative complications, so an intervention for smoking cessation during the preoperative period may be effective to reduce the incidences of complications. Moreover, the time of surgery may be a unique opportunity for smoking cessation attempts to succeed (Moller & Villebro, 2005).

There is evidence that interventions for smoking cessation, which include nicotine replacement therapy (NRT), increase for a short term the rate of smoking cessation and decrease postoperative morbidity. In this process it remains unclear which treatment intensity is optimal. Derived from indirect comparisons, the interventions that begin from 4 to 8 weeks before surgery, based on weekly counselling and the NRT are the most effective to quit smoking and to prevent long-term postoperative complications (Moller & Villebro, 2005).

#### **5.2 Pulmonary rehabilitation**

Pulmonary rehabilitation, that includes exercise and education, is effective in candidates for lung volume reduction and in the pre-and postoperative period of lung transplantation (Nici et al., 2006). However, this effectiveness is not clearly demonstrated in surgical patients with lung cancer.

Taking into account these issues the ERS / ESTS Task Force has recently published its algorithm based fundamentally on the performance of exercise tests when preoperative FEV1 or DLCO is less than 80%. If in the exercise test VO2 peak is less than 35% or 10 mL/kg/min, it should not be recommendable to perform pneumonectomy or lobectomy, but if it is higher than 75% or 20 mL/kg/min, any resection (including pneumonectomy) would be indicated. If the VO2 peak is between these cutoff values, it would be advisable to calculate ppo-FEV1 and ppo-DLCO. If these are greater than 30%, lung resection would be indicated according to the calculated extension, and if, at least, one of these parameters is less than 30% it would be necessary to calculate the ppo-VO2 peak. After its calculation and if it is greater than 35% or 10 mL/kg/min, resection would be indicated depending on the calculated extension, and if its value is less than this cutoff, neither pneumonectomy nor lobectomy would be recommended. Finally, if it is impossible to perform cardiopulmonary exercise test and calculate the VO2 peak, it is recommendable to carry out the stair climbing test, but if the reached altitude is less than 22 meters, its calculation would be advisable

One limitation in this type of algorithms, focusing on the completion of cardiopulmonary exercise testing, is that some candidates for lung resection are unable to execute any kind of exercise test due to the burden of concomitant comorbidities. These patients have demonstrated increased mortality after lung resection (Brunelli et al., 2005) and, after careful selection based on cardiopulmonary parameters they should be considered as high-risk

The use of bronchodilators, corticosteroids or a combination of both, as well as pulmonary rehabilitation and smoking cessation can help reduce postoperative complications occurring after thoracic surgery, especially in patients with comorbidities who present declining

Smokers have significantly higher risk of postoperative complications, so an intervention for smoking cessation during the preoperative period may be effective to reduce the incidences of complications. Moreover, the time of surgery may be a unique opportunity for smoking

There is evidence that interventions for smoking cessation, which include nicotine replacement therapy (NRT), increase for a short term the rate of smoking cessation and decrease postoperative morbidity. In this process it remains unclear which treatment intensity is optimal. Derived from indirect comparisons, the interventions that begin from 4 to 8 weeks before surgery, based on weekly counselling and the NRT are the most effective to quit smoking and to prevent long-term postoperative complications (Moller & Villebro,

Pulmonary rehabilitation, that includes exercise and education, is effective in candidates for lung volume reduction and in the pre-and postoperative period of lung transplantation (Nici et al., 2006). However, this effectiveness is not clearly demonstrated in surgical

(Brunelli et al., 2009 ) (figure 4).

**5. Patient care managment** 

values of FEV1 or DLCO.

**5.1 Smoking cessation** 

**5.2 Pulmonary rehabilitation** 

patients with lung cancer.

2005).

patients and candidates to be perioperatively monitored.

cessation attempts to succeed (Moller & Villebro, 2005).

Before the surgery, the preoperative VO2 is inversely proportional to the probability of the presence of complications after lung resection (Wu et al., 2002), which, in turn, is associated with postoperative loss of lung function (Nagamatsu et al., 2007). In addition, pulmonary rehabilitation improves VO2 before the surgery in patients with COPD with low VO2 (less than 15 mL/kg/min), which reduces late complications without affecting the operability or the prognosis (Bobbio et al., 2008).

Preoperative training programs lead to a reduction of hospital stay and of complications in patients with COPD and lung cancer (Sekine et al., 2005). However, improved accessibility to intervention has been observed only in patients with "quasi normal" lung function (Lovin et al., 2006). Pulmonary rehabilitation in inpatients has shown benefits in exercise capacity and lung volumes (Cesario et al., 2007).

Therefore, in the light of the data presented, it seems logical that pulmonary rehabilitation may decrease the complication rate in candidates for lung resection, which is why future researches on the content and duration of rehabilitation programs are priorities.

#### **5.3 Pharmacologic therapy**

The diagnosis of COPD is often established during the preoperative functional assessment in patients scheduled for lung resection after the diagnosis of lung cancer. These patients, with a high percentage of respiratory complications, may be excluded from surgery if we fail to achieve, with proper treatment, a sufficient pulmonary function value.

The main guidelines for the management of COPD patients who are to undergo lung resection indicate that it is necessary that the patient quit smoking, do exercises in pulmonary rehabilitation and optimize proper treatment to improve lung function and reduce postoperative complications (Brunelli et al., 2009). However, the treatments indicated for patients with COPD and lung cancer do not differ from those which are recommended to patients who have only COPD, in which a short-term therapeutic effect is not expected.

In the scientific literature we have found only few studies that evaluate the short and long term effect of initiation of therapy in patients with COPD and lung cancer. Several of them value the effect of tiotropium on lung function, establishing its improvement up to 226ml in FEV1 (Kobayashi et al., 2009), but without any effect on post sugery complications (Ueda et al. 2010). In a recent study, the treatment with formoterol and budesonide added to tiotropium improved the FEV1 in 310ml and decreased the number of postoperative pulmonary complications (Bölükbas et al., 2011). One of the keys to these results is the improvement in lung function that occurs when adding corticosteroids to long-acting bronchodilators. Another key is the improvement in FEV1 due to these drugs, since its value, both pre-and postoperative, is associated with mortality and morbidity after the surgery. Therefore, an elevation of FEV1 can increase the number of candidates for surgical resection, thus optimizing the treatment of cancer and improve the prognosis of these patients.

#### **6. Conclusion**

A lot of scientific literature dedicated to pre-operative evaluation before surgical treatment of lung diseases has been published. The search for the ideal preoperative test to predict major perioperative risk of patients began with the use of spirometry in 1955. Since then, scientific evidence allowing the stratification of perioperative risk based in different preoperative pulmonary function tests, estimations of postoperative lung function,

Perioperative Pulmonary Functional Assessment 387

Boushy, SF.; Biling, DM.; North, LB & Helgason, AH. (1971). Clinical course related to

Brunelli, A.; Refai, M.; Xiume, F.; Salati, M.; Sciarra, V.; Socc, L. & Sabbatini,m A. (2008)

BTS guidelines: guidelines on the selection of patients with lung cancer for surgery. (2001).

Cesario, A.; Ferri, L.; Galetta, D.; Pasqua, F.; Bonassi, S.; Clini, E.; Biscione, G.; Cardaci, V.; di

Colice, GL.; Shafazand, S.; Griffin, JP.; Keenan, R.; Bolliger, CT. & American College of Chest

Eugene J, Brown SE, Light RW. (1982). Maximun oxygen consumption: a physiologic guide to pulmonary serection. *Surg Forum*, Vol.33:,(1982), pp.260-2. ISSN 0071-8041. Ferguson, MK.; Little, L.; Rizzo, L.; Popovich, KL.; Glonek, GF.; Leff, A.; Manjoney, D. &

Ferguson, MK. & Vigneswaran, WT. (2008). Diffusing capacity predicts morbidity after lung

Gass, GD. & Olsen, GN. (1986). Preoperative pulmonary function testing to predict

Juliá Serdá G, Ramírez Rodríguez R, Cabrera López C, Freixinet Gilart J. (2010) Aplicación

Toro, S.; Zarzana, A.; Margaritora, S.; Piraino, A.; Russo, P.; Sterzi, S. & Granone, P. (2007). Post-operative respiratory rehabilitation after lung resection for non-small cell lung cancer. *Lung Cancer*, Vol.57, No.2, (April 2007), pp.175–180. ISSN 0169-

Physicians. (2007). Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition). *Chest*, Vol.132, Suppl.3, (September 2007), pp.161S–177S.

Little, AG. (1988). Diffusing capacity predicts morbidity and mortality after pulmonary resection. *J Thorac Cardiovasc Surg*, Vol.96, No.6, (December 1988),

resection in patients without obstructive lung disease. *Ann Thorac Surg*, Vol.85,

postoperative morbidity and mortality. *Chest*. Vol.89, No.1, (January 1986), pp.127-

de las pruebas de function cardiopulmonary en la práctica quirúrgica. In: *Tratado de Cirugía Torácica*, Fernández Fau L, Freisinet Gilart J, (Ed), pp.187-203, EDIMSA,

*Thorax*, Vol.56, No.2, (February 2001), pp.89–108. ISSN 0040-6376.

*Ann Thorac Surg*, Vol.86, No.1 (July 2008), pp.240–247. ISSN 0003-4975. Brunelli, A.; Charloux, A.; Bolliger, CT.; Rocco, G.; Sculier, JP.; Varela, G.; Licker, M.;

carcinoma. *Chest*, Vol.59, No.4, (April 1971), pp.383-91. ISSN 0012-3692. Brunelli, A.; Sabbatini, A.; Xiume, F.; Borri, A.; Salati, M.; Marasco, RD. & Finachini, A.

(January 2005), pp.367–372. ISSN 1010-7940.

pp.17–41. ISSN 0903 – 1936.

5002.

ISSN 0012-3692.

pp.894-900. ISSN: 0022-5223.

35. ISSN 0012-3692.

No.4 (April 2008), pp.1158–1164. ISSN 0003-4975.

ISBN 987-84-7714-341-3, Madrid, Spain.

preoperative and postoperative pulmonary function in patients with bronchogenic

(2005). Inability to perform maximal stair climbing test before lung resection: a propensity score analysis on early outcome. *Eur J Cardiothorac Surg,* Vol.27, No.3,

Performance at symptom limited stair-climbing test is associated with increased ciardiopulmonary complications, mortality, and costs after major lung resection.

Ferguson, MK.; FAivre-Finn, C.; Huber, RM.; Clini, EM.; Win, T.; De Ruysscher, D. & Goldman, L. on behalf of the European Respiratory Society and European Society of Thoracic Surgeons joint task force on fitness for radical therapy. (2009). ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). *Eur Respir J*, Vol.34, No.1 (September 2009),

pulmonary circulation hemodynamics, arterial blood gases or exercise testing has been given. Therefore, the functional assessment has undergone major changes; apart from preoperative measurement of pulmonary function (FEV1, DLCO or VO2 peak) is getting more and more importance.

In the last few years, a number of decision-making algorithms interpreting the abundant literature on the issue have been described. These algorithms are mainly based on that postoperative FEV1 should not to be used alone to select patients for lung resection. DLCO should be routinely measured during pre-operative evaluation of lung resection candidates (regardless of whether the spirometric evaluation is abnormal or not). A postoperative FEV1 and DLCO values of 30% predicted is suggested to be a high risk threshold for this parameter when included in an algorithm for assessment of pulmonary reserve before surgery, exercise tests should be indicated for all the patients undergoing surgery with FEV1 or a DLCO < 80% of normal values and either ventilation scintigraphy or perfusion scintigraphy offer good prediction of post-operative lung function.

Finally, the main recommendation to the patients on which lung resection will be performed is to give up smoking for sufficient spell (at least 2–4 weeks) before the surgery, since it may decrease post-operative complications. Moreover, early pre- and post-operative rehabilitation should also be recommended, since it may produce functional benefits in patients with resected lung.

#### **7. References**


pulmonary circulation hemodynamics, arterial blood gases or exercise testing has been given. Therefore, the functional assessment has undergone major changes; apart from preoperative measurement of pulmonary function (FEV1, DLCO or VO2 peak) is getting

In the last few years, a number of decision-making algorithms interpreting the abundant literature on the issue have been described. These algorithms are mainly based on that postoperative FEV1 should not to be used alone to select patients for lung resection. DLCO should be routinely measured during pre-operative evaluation of lung resection candidates (regardless of whether the spirometric evaluation is abnormal or not). A postoperative FEV1 and DLCO values of 30% predicted is suggested to be a high risk threshold for this parameter when included in an algorithm for assessment of pulmonary reserve before surgery, exercise tests should be indicated for all the patients undergoing surgery with FEV1 or a DLCO < 80% of normal values and either ventilation scintigraphy or perfusion

Finally, the main recommendation to the patients on which lung resection will be performed is to give up smoking for sufficient spell (at least 2–4 weeks) before the surgery, since it may decrease post-operative complications. Moreover, early pre- and post-operative rehabilitation should also be recommended, since it may produce functional benefits in

American Thoracic Society; American College of Chest Physicians. ATS /ACCP Statement

Beckles, MA.; Spiro, SG.; Colice, GL. & Rudd, RM; American College of Chest Physician.

Bobbio, A.; Chetta, A.; Ampollini, L.; Primomo, GL.; Internullo, E.; Carbognani, P.; Rusca,

Bolliger, C.; Jordan, P.; Soler, M.; Stulz, P.; Grädel, E.; Skarvan, K.; Elsasser, S.; Gonon, M.;

Bolliger, C.; Wyser, C.; Roser, H.; Soler, M. & Perruchoud, AP. (1995). Lung scanning and

Bölükbas, S.; Eberlein, M.; Eckhoff, J. & Schirren, J. (2011). Short-term effects of inhalative

on cardiopulmonary exercise testing. (2003). *Am J Respir Crit Care Med*, Vol.167,

(2003). The physiologic evaluation of patients with lung cancer being considered for resectional surgery Chest*,* Vol.123, No.1 Suppl, (January 2003), pp.105S-114S.

M. & Olivieri D. (2008). Preoperative pulmonary rehabilitation in patients undergoing lung resection for nonsmall cell lung cancer. *Eur J Cardiothorac Surg*,

Wyser, C. & Tamn, M. (1995). Exercise capacity as a predictor as postoperative complications in lung resection candidates. *Am J Respir Crit Care Med*, Vol.151 No.5,

exercise testing for the prediction of postoperative perfonmance in lung resection candidates at increased risk for complications. *Chest*, Vol.108, No.2 (August 1995),

tiotropium/formoterol/budesonide versus tiotropium/formoterol in patients with newly diagnosed chronic obstructive pulmonary disease requiring surgery for lung cancer: a prospective randomized trial. *European Journal of Cardio-thoracic Surgery*,

scintigraphy offer good prediction of post-operative lung function.

No.10, (May 2003), pp.211-77. ISSN 1073-449X.

(May 1995), pp.1472-80. ISSN 1073-449X.

pp.341-8. ISSN 0012-3692.

Vol.33, No.1, (November 2007), pp.95–98. ISSN 1010-7940.

Vol.39, No.6, (October 2010), pp.995-1000. ISSN 1010-7940.

more and more importance.

patients with resected lung.

ISSN 0012-3692.

**7. References** 


Perioperative Pulmonary Functional Assessment 389

Ninan, M. ; Sommers, KE.; Landreneau, RJ.; Weyant, RJ.; Tobias, J.; Luketich, JD.; Ferson, PF.

Ohno, Y.; Koyama, H.; Nogami, M.; Takenaka, D.; Matsumoto, S.; Yoshinura, M.; Kotani, Y.

Olsen, GN.; Block, AJ. & Tobias, JA. (1974). Prediction of postpneumonectomy pulmonary

Olsen, GN.; Block, AJ.; Swenson, EW.; Castle, JR. & Wynne, JW. (1975). Pulmonary function

Olsen, GN.; Bolton, JW.; Weiman, DS. & Hornung, GA. (1991). Stair climbing as an exercise

experience. *Chest*, Vol.99, No.3, (March 1991), pp.587–590. ISSN 0012-3692. Pierce, RJ.; Copland, JM.; Sharpe, K. & Barter, CE. (1994). Preoperative risk evaluation for

Puente Maestu, L. & Ruiz Martín, JJ. (2003). Stress testing and lung resection surgery. *Arch Bronconeumol*, Vol.39, No.3, (March 2003), pp.126-132. ISSN 0300-2896. Richter Larsen, K.; Svendsen, UG.; Milman, N.; Brenoe, J. & Petersen, BN. (1997). Exercise

Schuurmans, MM.; Diacon, AH. & Bolliger, CT. (2002). Functional evaluation before lung resection*. Clin Chest Med*, Vol.23, No.1 (March 2002), pp.159-72. ISSN 0272-5231. Sekine, Y.; Iwata, T.; Chiyo, M.; Yasufuku, K.; Motohashi, S.; Yoshida, S.; Suzuki, M.; Iizasa,

*Thorac Surg*, Vol.76, No.2 (August 2003), pp.356–361. ISSN 0003-4975. Sekine, Y.; Chiyo, M.; Iwata, T.; Yasufuku, K.; Furukawa, S.; Amada, Y.; Iyoda, A.; Shibuya,

*Cardiovasc Surg,* Vol.53, No.5, (May 2005), pp.237–243. ISSN 0368-2811. Singh, SJ.; Morgan, MD.; Hardman, AE.; Rowe, C. & Bardsley, PA. (1994). Comparison of

Smith, TP.; Kinasewitz, GT.; Tucker, WY.; Spillers, WP. & George, RB. (1984). Exercise

*Repir J*, Vol.10, No.7 (July 1997), pp.1559-65. ISSN 0903 – 1936.

*Roentgenol*, 189, No.2, (August 2007), pp.400-8. ISSN 0361-803X.

Vol.111, No.4, (April 1975), pp.379-87. ISSN 0003-0805.

ISSN 1073-449X.

1974), pp.13-6. ISSN 0012-3692.

4975.

1073-449X.

2020. ISSN 0903 – 1936.

No.5, (May 1984), pp.730-4. ISSN 0003-0805.

rehabilitation. *Am J Respir Crit Care Med*, Vol.173, No.12, (June 2006), pp.1390–1413.

& Kenan, RJ. (1997). Standardized exercise oximetry predicts postpneumonectomy outcome. *Ann Thorac Surg*, Vol.64, No.2, (August 1997), pp.328–332. ISSN 0003-

& Sugimura, K. (2007). Postoperative lung function in lung cancer patients: comparative analysis of predictive capability of MRI, CT and SPECT. *AJR Am J* 

function using quantitative macroaggregate lung scaning. *Chest*, Vol.66, No.1, (July

evaluation of the lung resection candidate: a prospective study. *Am Rev Respir Dis*,

test to predict the postoperative complications of lung resection. Two years'

lung cancer resection: predicted postoperative product as a predictor of surgical mortality. *Am J Respir Crit Care Med*, Vol.150, No.4 (October 1994), pp.947–955. ISSN

testing in the preoperative evaluation of patients with bronchogenic carcinoma. *Eur* 

T.; Saitoh, Y. & Fujisawa, T. (2003). Minimal alteration of pulmonary function after lobectomy in lung cancer patients with chronic obstructive pulmonary disease. *Ann* 

K.; Iizasa, T. & Fujisawa, T. (2005). Perioperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease. *Jpn J Thorac* 

oxygen uptake during a conventional treadmill test and the shuttle walking test in chronic airflow limitation. *Eur Respir J*, Vol.7, No.11, (November 1994). pp.2016–

capacity as a predictor of post-thoracotomy morbidity. *Am Rev Respir Dis*, Vol.129.


Kobayashi, S.; Suzuki, S.; Niikawa, H.; Sugawara, T. & Yanai, M. (2009). Preoperative use of

Kristersson, S..; Lindell, SE, & Svanberg, L. (1972) Prediction of pulmonary function loss due

Little, AG.; Rusch, VW.; Bonner, JA.; Gaspar, LE.; Green, MR.; Webb, WR. & Stewart, AK.

Lockwood P. (1973). Lung function test results and the risk of post-thoracotomy complications. *Respiration*, Vol.30, No.6, (1973), pp.529-42. ISSN 0025-7931. Lovin, S. ; Bouille, S. ; Orliaguet, O & Veale, D. (2006). [Preoperative rehabilitation in the

Markos, J.; Mullan, BP.; Hillman, DR.; Musk, AW.; Antico, VF.; Lovegrove, FT.; Carter, MJ.

Marshall, MC. & Olsen, GN. (1993). The physiologic evaluation of the lung resection candidate. *Clin Chest Med*, Vol.14, No.2, (June 1993), pp.305-20. ISSN 0272-5231. Meyer-Erkelenz, JD.; Mösges, RW. & Sieverts, H. (1980). Speiroergometry (cardiopulmonary

*Klin Pneumol*, Vo.34, No.10 (October 1980), pp.585-600. ISSN 0342-7498. Miller, JI.; Grossman, GD. & Hatcher, CR. (1981). Pulmonary function test criteria for

Mittman, C. & Bruderman, I. (1977). Lung cancer: to operate or not? *Am Rev Respir Dis*

Miyoshi, S.; Nakahara, K.; Ohno, K.; Monden, Y. & Kawashima, Y. (1989). Exercise tolerance

Moller, A. & Villebro, N. (2005). Interventions for preoperative smoking cessation. *Cochrane Database Syst Rev*, Vol.20, No.3, (July 2005), pp.CD002294. ISSN 1469-493X. Morice, RC.; Peters, EJ.; Ryan, MB.; Putnam, JB.; Ali, MK. & Roth, JA. (1992). Exsercise

resection. *Chest*, Vol.101, No.2, (February 1992), pp.356-61. ISSN 0012-3692. Nagamatsu, Y.; Maeshiro, K.; Kimura, NY.; Nishi, T.; Shima, I.; Yamana, H. & Shirouzo, K.

Nakahara, K.; Monden, Y.; Ohno, K.; Miyoshi, S.; Maeda, H. & Kawashima, Y. (1985). A

Nici, L. & ATS/ERS Pulmonary Rehabilitation Writing Committee. (2006). American

Vol.116, No.3, (September 1977), pp.477-96. ISSN 0003-0805.

Vol.14, No.5, (May 2009), pp.675-9. ISSN 1323-7799.

No.6, (December 2005), pp.2051-6. ISSN 0003-4975.

1972), pp.694-8. ISSN 0012-3692.

2006), pp.109–112. ISSN 2067-2993.

pp.902-10. ISSN 0003-0805.

1981), pp.893-5. ISSN 0039-6087.

ISSN 0003-4975.

ISSN: 0022-5223.

1985), pp.260–265. ISSN 0003-4975.

inhaled tiotropium in lung cancer patients with untreated COPD. *Respirology*,

to pneumonectomy using 133 Xe-radiospirometry. *Chest*, vol.62. No.6, (December

(2005). Patterns of surgical care of lung cancer patients. *Ann Thorac Surg*, Vol.80,

surgical treatment of lung cancer]. *Pneumologia*, Vol.55, No.3, (July-September

& Finucane, KE. (1989). Preoperative assessment as a predictor of mortality and morbidity after lung resection. *Am Rev Respir Dis*, Vol.139, No.4, (April 1989),

function under load). Reporto f the results of the 1979 colloquium in Aachen. *Prax* 

operability and pulmonary resection. *Surg Gynecol Obstet*, Vol.153. No.6, (December

test in lung cancer patients: the relationship between exercise capacity and postthoracotomy hospital mortality. *Ann Thorac Surg*, Vol.44, (1989), pp.487-90.

testing in the evaluation of patiens at high risk for complications fron lung

(2007). Long-term recovery of exercise capacity and pulmonary function after lobectomy. *J Thorac Cardiovasc Surg,* Vol.134, No.5, (November 2005), pp.1273–1278.

method for predicting postoperative lung function and its relation to postoperative complications in patients with lung cancer. *Ann Thorac Surg*, Vol.39, No.3, (March

Thoracic Society/ European Respiratory Society statement on pulmonary

rehabilitation. *Am J Respir Crit Care Med*, Vol.173, No.12, (June 2006), pp.1390–1413. ISSN 1073-449X.


**21** 

 *Italia* 

**Post Thoracotomy Pain Syndrome** 

 *Azienda Ospedaliera Maggiore della Carità, Novara,* 

F. Della Corte, C. Mendola, A. Messina and G. Cammarota

Post-thoracotomy pain is one of the most severe and long lasting complications after surgery (1-4) which acutely contributes to limit normal respiratory activity impairing the sputum clearance and reducing ventilatory function (5). Along with limb amputation, thoracotomy is the surgical procedure with the highest risk of severe and long lasting acute postoperative

Moreover, a chronic post thoracotomy pain syndrome (PTPS) may delay the long term rehabilitation, worsening the quality of life because of the associated neuropathic pain even without recurrences of the primary disease (7). Lung cancer still remains the first cause of death for cancer (8) and prompt pulmonary surgery may be the only effective therapeutic strategy. Consequently, an increasing rate of thoracic surgery will be progressively

The syndrome was firstly described in 1944 during the II world war when American surgeons reported persistent intercostal pain in soldiers submitted to thoracotomy (9). Until the end of the nineties, pain treatment was mainly based on intravenous opioids and the

The International Association for the Study of Pain (IASP) definition of Post Thoracotomy Pain Syndrome is the following: 'Pain that recurs or persists along a thoracotomy scar at

PTPS incidence between 11 and 80% has been reported in the literature (11-13). This variability is probably related to the setting of retrospective studies, the lack of an homogeneous definition of the severity and duration of the syndrome, the difference in anesthetic and analgesic protocols, the use of different pain evaluation scales and the time of postoperative follow-up. Moreover, the high variability in PTPS incidence may also be

PTPS is mostly described with the typical characteristics of neuropathic pain, often related to the surgical scar, since 82—90% of pain patients recognize the pain trigger directly to the surgical site (1, 10). Pain is primarily described as aching, tender, with numbness and to a lesser degree burning (1, 15); however, PTPS is sometimes described as tingling and pruritus sensation within the thoracic injured area. Finally, thoracic sensory deficits are referred by

associated with a higher PTPS incidence in the future.

least 2 months following surgical procedure' (7).

**3. Pain characteristics after thoracic surgery** 

**2. Definition and incidence** 

incidence of PTPS was about 61% one year after surgery (10).

explained by the different attitude of patients towards discomfort (14).

**1. Introduction** 

pain (6).

