Analysis of 11 Trials Comparing Muscle-Sparing with Posterolateral Thoracotomy

Abstract

Background Muscle-sparing thoracotomy (MST) has recently been developed in an attempt to minimize tissue injuries during thoracic operation and postoperative sequelae. However, its potential advantages over traditional posterolateral thoracotomy (PLT) remain to be determined. Here, we performed a meta-analysis on all available studies that compare the pros and cons between the two approaches.

Methods A total of 11 relevant studies were found to satisfy our inclusive criteria from three electronic databases. End points included postoperative pain, pulmonary function, postoperative mortality, and perioperative complications.

Results Data from seven randomized controlled trials and four observational studies were included (n = 408 and 564, respectively). Compared with PLT group, MST group had a significantly reduced postoperative visual analog scale score on day 1 (weighted mean difference [WMD], −0.79; 95% confidence interval [CI], −1.10 to −0.48), week 1 (WMD, −0.60; 95% CI, −0.98 to −0.22), and month 1 (WMD, −0.73; 95% CI, −1.30 to −0.16). However, no difference between the two approaches was found on postoperative forced vital capacity and forced expiratory volume in 1 second (week 1: standardized mean difference [SMD], 0.44; 95% CI, −0.18 to 1.07 versus SMD, 0.53; 95% CI, −0.13 to 1.18; month 1: SMD 0.26; 95% CI, −0.26 to 0.78 versus SMD, 0.38; 95% CI, −0.25 to 1.00), mortality (odds ratio [OR], 1.23; 95% CI, 0.49 to 3.09), and complications (OR, 0.86; 95% CI, 0.60 to 1.23).

Conclusions MST may improve postoperative pain, but shows less effect on other perioperative parameters.

Keywords

surgery/incisions - chest wall - pulmonary function - surgery - complications - outcomes (includes mortality and morbidity)

• References

• 1 Endoh H, Tanaka S, Yajima T , et al. Pulmonary function after pulmonary resection by posterior thoracotomy, anterior thoracotomy or video-assisted surgery. Eur J Cardiothorac Surg 2010; 37 (5) 1209-1214
• 2 Lemmer Jr JH, Gomez MN, Symreng T, Ross AF, Rossi NP. Limited lateral thoracotomy. Improved postoperative pulmonary function. Arch Surg 1990; 125 (7) 873-877
• 3 Nomori H, Ohtsuka T, Horio H, Naruke T, Suemasu K. Difference in the impairment of vital capacity and 6-minute walking after a lobectomy performed by thoracoscopic surgery, an anterior limited thoracotomy, an anteroaxillary thoracotomy, and a posterolateral thoracotomy. Surg Today 2003; 33 (1) 7-12
• 4 Nosotti M, Baisi A, Mendogni P, Palleschi A, Tosi D, Rosso L. Muscle sparing versus posterolateral thoracotomy for pulmonary lobectomy: randomised controlled trial. Interact Cardiovasc Thorac Surg 2010; 11 (4) 415-419
• 5 Nomori H, Horio H, Suemasu K. Anterior limited thoracotomy with intrathoracic illumination for lung cancer: its advantages over anteroaxillary and posterolateral thoracotomy. Chest 1999; 115 (3) 874-880
• 6 Landreneau RJ, Pigula F, Luketich JD , et al. Acute and chronic morbidity differences between muscle-sparing and standard lateral thoracotomies. J Thorac Cardiovasc Surg 1996; 112 (5) 1346-1350 , discussion 1350–1351
• 7 Ponn RB, Ferneini A, D'Agostino RS, Toole AL, Stern H. Comparison of late pulmonary function after posterolateral and muscle-sparing thoracotomy. Ann Thorac Surg 1992; 53 (4) 675-679
• 8 Hazelrigg SR, Landreneau RJ, Boley TM , et al. The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain. J Thorac Cardiovasc Surg 1991; 101 (3) 394-400 , discussion 400–401
• 9 Ochroch EA, Gottschalk A, Augoustides JG, Aukburg SJ, Kaiser LR, Shrager JB. Pain and physical function are similar following axillary, muscle-sparing vs posterolateral thoracotomy. Chest 2005; 128 (4) 2664-2670
• 10 Ochroch EA, Gottschalk A, Augostides J , et al. Long-term pain and activity during recovery from major thoracotomy using thoracic epidural analgesia. Anesthesiology 2002; 97 (5) 1234-1244
• 11 Nomori H, Horio H, Fuyuno G, Kobayashi R. Non-serratus-sparing antero-axillary thoracotomy with disconnection of anterior rib cartilage. Improvement in postoperative pulmonary function and pain in comparison to posterolateral thoracotomy. Chest 1997; 111 (3) 572-576
• 12 Sugi K, Nawata S, Kaneda Y, Nawata K, Ueda K, Esato K. Disadvantages of muscle-sparing thoracotomy in patients with lung cancer. World J Surg 1996; 20 (5) 551-555
• 13 Athanassiadi K, Kakaris S, Theakos N, Skottis I. Muscle-sparing versus posterolateral thoracotomy: a prospective study. Eur J Cardiothorac Surg 2007; 31 (3) 496-499 , discussion 499–500
• 14 Įobanoğlu U, Hız Ö, Melek M, Edirne Y. Is muscle-sparing thoracotomy advantageous?. Turkish J Thorac Cardiovasc Surg. 2011; 19 (1) 43-48
• 15 Akçali Y, Demir H, Tezcan B. The effect of standard posterolateral versus muscle-sparing thoracotomy on multiple parameters. Ann Thorac Surg 2003; 76 (4) 1050-1054
• 16 Soucy P, Bass J, Evans M. The muscle-sparing thoracotomy in infants and children. J Pediatr Surg 1991; 26 (11) 1323-1325
• 17 Khan IH, McManus KG, McCraith A, McGuigan JA. Muscle sparing thoracotomy: a biomechanical analysis confirms preservation of muscle strength but no improvement in wound discomfort. Eur J Cardiothorac Surg 2000; 18 (6) 656-661
• 18 Benedetti F, Vighetti S, Ricco C , et al. Neurophysiologic assessment of nerve impairment in posterolateral and muscle-sparing thoracotomy. J Thorac Cardiovasc Surg 1998; 115 (4) 841-847
• 19 Wildgaard K, Ravn J, Kehlet H. Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg 2009; 36 (1) 170-180
• 20 Khelemsky Y, Noto CJ. Preventing post-thoracotomy pain syndrome. Mt Sinai J Med 2012; 79 (1) 133-139
• 21 Durrleman N, Pryshipov M, Wihlm JM, Massard G. Safe treatment of post thoracotomy seroma. Asian Cardiovasc Thorac Ann 2007; 15 (3) e43-e45
• 22 Bethencourt DM, Holmes EC. Muscle-sparing posterolateral thoracotomy. Ann Thorac Surg 1988; 45 (3) 337-339
• 23 Black N. Why we need observational studies to evaluate the effectiveness of health care. BMJ 1996; 312 (7040) 1215-1218
• 24 Kirtane AJ, Gupta A, Iyengar S , et al. Safety and efficacy of drug-eluting and bare metal stents: comprehensive meta-analysis of randomized trials and observational studies. Circulation 2009; 119 (25) 3198-3206
• 25 Jüni P, Witschi A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA 1999; 282 (11) 1054-1060
• 26 Hannan EL. Randomized clinical trials and observational studies: guidelines for assessing respective strengths and limitations. JACC Cardiovasc Interv 2008; 1 (3) 211-217