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- Hindawi Publishing Corporation
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- Copyright © 2022 Jing Peng et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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- 10.1155/2022/7584481
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Abstract
Hindawi Journal of Healthcare Engineering Volume 2022, Article ID 7584481, 7 pages https://doi.org/10.1155/2022/7584481 Research Article Incidence and Influencing Factors of Chronic Postthoracotomy Pain in Lung Tumor Patients Jing Peng , Zhonghui Wang, Liang Ma, Weihao Ma, Guo Liu, Hui Zhang, Qiongchuan Wang, Bobo Zhu, and Li Zhao Department of Anesthesiology, e ird Affiliated Hospital of Kunming Medical University (Yunnan Cancer Hospital), Kinming 650118, Yunnan, China Correspondence should be addressed to Li Zhao; zhaoli@kmmu.edu.cn Received 12 November 2021; Revised 22 December 2021; Accepted 10 January 2022; Published 24 February 2022 Academic Editor: Rahim Khan Copyright © 2022 Jing Peng et al. )is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. To estimate the incidence of chronic postthoracotomy pain (CPTP) in lung tumor patients and to explore the influencing factors of the intensity of CPTP. Methods. Lung tumor patients who underwent video-assisted thoracoscopic surgery (VATS) or thoracotomy were consecutively recruited from October 2016 to December 2017 at Yunnan Cancer Hospital. All the eligible patients were interviewed via telephone at the end of the third month after surgeries to identify the presence of CPTP. )e potential influencing factors of CPTP, including pre-, intra-, and postoperative variables, were collected from medical records. A cumulative logit regression model was used to identify the independent influencing factors of the intensity of CPTP. Results. )ree hundred and forty-three patients completed a telephone interview. )e estimated overall incidence of CPTP was 67.6% (95% of confidence interval, 95% CI: 62.4%, 72.6%) in lung tumor patients; 70.8% (95% CI: 63.8%, 77.1%) in benign patients and 63.5% (95% CI: 55.2%, 71.3%) in malignant patients; and 78.1% (95% CI: 66.0%, 87.5%) in open chest and 65.2% (95% CI: 59.3%, 70.8%) in VATS. Cumulative logit regression models (intensity order, NRS, 0⟶1–3⟶4-) revealed independent influencing factors of CPTP to be patients with diabetes (OR �0.32; 95% CI: 0.14, 0.76), usage of VATS (OR �0.47; 95% CI: 027, 0.82), and the amount of intraoperative blood loss (OR �1.09; 95% CI: 1.00, 1.19). Conclusions. A high incidence of CPTP is detected in lung tumor patients following the thoracic operation. Patients with diabetes and using VATS are the independent protective factors of the intensity of CPTP, and the increasing amount of intraoperative blood loss is an independent risk factor of the intensity of CPTP. surgery, duration of chest tube drainage, and so on; nev- 1. Background ertheless, these influencing factors relatively lack repeat- ability of studies. Although CPTP is one of the great Lung tumor is one of the common tumors and its incidence burdens in community health, the mechanism of CPTP is increased rapidly in recent years, especially, malignant still unknown; hence, the tracing of the predictors or risk tumor [1]. At present, thoracic operation that includes factors of CPTP is particularly important for prevention thoracotomy and video-assisted thoracoscopic surgery and prediction. )erefore, the aims of this study were to (VATS) is still the main treatment for lung tumors [2, 3]. estimate the incidence of CPTP in lung tumor patients and Despite the effective therapy, chronic postthoracotomy explore the influencing factors of CPTP. pain (CPTP) which is defined as pain persisting for at least 3 months after thoracic operations is accused of greatly reduced quality of life and increased morbidity [4]. Bayman 2. Methods and Brennan [5] reported that more than half of patients suffered CPTP; thus, it seriously influenced community 2.1. Subjects. Lung tumor patients who underwent VATS or health. Previous studies [6–10] have found that CPTP was thoracotomy were consecutively recruited from October influenced by age, sex, diabetes, properties of tumor, type of 2016 to December 2017 at Yunnan Cancer Hospital. 2 Journal of Healthcare Engineering Exclusion criteria include the following: (1) age less than extreme precautions were used to avoid the injury of in- 18 years; (2) histories of preoperative chemotherapy, pre- tercostal nerves. )e VATS approach used a uniform an- vious thoracic surgery, thoracic trauma, previous chest and terior single- or three-port technique with standardized port back pain, and previous other malignancies; (3) emergent placements regardless of the lobe to be resected or not. For operation; (4) reoperation was performed within 3 months the single-hole operation, the hole was made in the 5th or 4th after surgery; (5) postoperative pulmonary infection and intercostal space at the anterior axillary line, while the three surgical site infection; and (6) American Society of Anes- holes were located at the 3rd , 7th, and 9th intercostal space thesiologists (ASA) physical status greater than or equal to 3. at the anterior, middle, and posterior axillary lines, re- All subjects in this study were given verbal informed spectively. At the end of the surgery, two chest tubes were consent for their participation, and the oral informed inserted just similar to thoracotomy. )e draining chest tube consent process was approved by the Research Ethics was removed as soon as no air leakage was detected for more Committee of the Department of Anesthesiology at Yunnan than 24 hours, the total amount of pleural effusion was less Cancer Hospital. than 200ml per day, and no chylothorax or bleeding was present. A total intravenous anesthesia (TIVA) technique com- 2.2. Definition. According to the International Association posed of midazolam, propofol, sufentanil, and remifentanil, for the Study of Pain (IASP) [11], the CPTP is defined as and intermittent rocuronium was used to maintain adequate follows: (1) the pain developed in the operation area or anesthesia after induction. No paravertebral or epidural adjacent parts after the operation; (2) the pain lasted for at block was administered pre- or postoperatively. )e post- least three months; (3) the pain which was different from the operative pain management of all patients was patient- preoperative pain; and (4) other causes of the pain should be controlled infusion pump (PCIA), involving a programme excluded, such as advanced malignant tumor or chronic to deliver a total of 100ml of the mixture of sufentanil, infection. dextrozine, ondansetron, and saline within 48 hours with a continuous dose of 1-2 micrograms per hour, along with patient-controlled bolus of 2-3 micrograms at a lockout 2.3. Questionnaire Design and Telephone Interview. All the interval of 10 minutes. )e bolus dosage was subsequently eligible patients were interviewed via telephone at the end of adjusted and titrated for optimal analgesia (visual analogue the third month after surgeries; therefore, this study was scale (VAS) score less than 3). )e patients’ pain status was conducted from January 2017 to April 2018. )e telephone managed by a dedicated Acute Pain Service (APS) team from interviews were conducted by well-trained research team the Department of Anesthesiology and assessed on the third members to collect information of CPTP following day after surgery. appointments. According to the literature review and expert consul- tation, the data of demographic, pre-, intra-, and postop- 2.5. Analysis. Demographic, pre-, intra-, and postoperative erative variables were designed into a questionnaire and then variables were compared across the 3 levels of intensity of collected from the medical record after the consent of the CPTP using the Kruskal–Wallis test. Based on the results of patient. univariate analyses, variables were selected for inclusion in )e most critical aspect of this questionnaire is to initial cumulative logit regression models to identify the identify patients who had really experienced CPTP based on independent influencing factors of CPTP intensity. Model their responses to questions as follows: refinement was conducted using manual backward exclu- (1) ‘‘Have you experienced any pain along the scar after sion, sequentially removing variables not contributing sig- surgery, different from what you had before the nificantly to the fit of the model based on the change in log- surgery?’’ likelihood of successive models. All the significance tests were two-sided, and P values less than 0.05 were considered (2) ‘‘Has the pain persisted for at least 3 months?’’ statistical significance. If a participant answered “yes” for the presence of pain, patients were then further asked to report the severity of 3. Results their CPTP by the numerical rating scale (NRS) method as well as the ID pain questionnaire [12], which is used to )ree hundred and seventy-nine lung tumor patients who identify neuropathic pain in CPTP patients. underwent thoracic surgery were recruited in this study; thirty-five patients were lost to follow-up and one patient 2.4.Surgery,Anesthesia,andPostoperativePainManagement. died. )e remaining 343 patients finished the telephone Two different surgical teams were involved in this study, interview, giving a completion rate of 90%. Among these 343 with both thoracotomy and VATS. )e thoracotomy ap- patients, 232 were diagnosed as CPTP, and thus, the esti- proach used a conventionally lateral or posterior-lateral mated overall incidence of CPTP was 67.6% (95% of con- incision without rib resection during the operation. )e skin fidence interval, 95% CI: 62.4%, 72.6%) in the whole study incision was parallel to the ribs at the intercostal space. Chest sample; 78.1% (95% CI: 66.0%, 87.5%) in open chest and tubes (JINGLE , China, 26-Fr, Disposable Drainage Tube, 65.2% (95% CI: 59.3%, 70.8%) in VATS; and 70.8% (95% CI: and DIALL ) were placed before closing the chest, and 63.8%, 77.1%) in benign patients and 63.5% (95% CI: 55.2%, ® Journal of Healthcare Engineering 3 71.3%) in malignant patients; however, neither types of 100 surgery (P �0.393) nor the properties of tumor (P �0.155) differed significantly. Furthermore, among 232 CPTP pa- tients, 148 patients (63.8% (95% CI: 57.2%, 70.0%)) were identified as neuropathic pain in the current study. Figure 1 shows the distribution of NRS among CPTP patients, and most of them were less than 5. On the basis of the NRS distribution, the intensity of CPTP was defined as mild (NRS �1–3) and moderate or severe (NRS �4 and above, 4-), as well as non-CPTP (NRS �0) in this study. 20 Table 1 shows the general characteristics of patients according to the 3 levels of NRS. Sex, age, height, weight, smoking, and drinking showed no significant difference 1 2 3 45 6 78 9 across the levels. Figure 2 compares the distribution of NRS the properties of tumor across the 3 levels; similar to Figure 1: Distribution of NRS among CPTP patients. CPTP, general characteristics, the difference was without chronic postthoracotomy pain; NRS, numerical rating scale. significance. Pre-, intra-, and postoperative variables are shown in Table 2. In this study, the percentages of non-CPTP patients Table 1: )e general characteristics of lung tumor patients with thoracic surgery according to the three levels of NRS scores. suffering from diabetes and hypertension were relatively higher than those of CPTP patients. Moreover, the usage of Items 0, n �111 1–3, n �169 4–, n �63 P VATS significantly differed across the 3 levels of NRS. In Sex 0.904 Figure 3, the CPTP groups relatively had higher proportions Male 63 (56.8) 99 (58.6) 35 (55.6) of using spreader than non-CPTP group; however, the using Female 48 (43.2) 70 (41.4) 28 (44.4) time of spreader among the 3 groups did not show signif- Age (years) 53.59±9.76 51.65±10.62 53.79±11.91 0.149 icant difference. Height (cm) 163.56±6.91 164.06±7.96 162.05±6.04 0.130 Table 2 also shows the patients’ ASA physical status Weight (kg) 61.85±9.94 62.01±10.56 60.59±11.23 0.445 BMI 23.22±3.73 23.02±3.21 23.09±3.69 ranged from I to II, and no significant difference was found Educated 0.121 among the 3 groups. Similarly, type of procedure, intra- No 50 (45.0) 96 (56.8) 36 (57.1) operative intercostal nerve block, postoperative hospital Yes 61 (55.0) 73 (43.2) 27 (42.9) stays, postoperative morphine use, duration of drainage, and Smoking 0.636 postoperative antibiotic use also showed nonsignificant No 69 (62.2) 112 (66.3) 38 (60.3) difference across the 3 groups. )e values of preoperative Yes 42 (37.8) 57 (33.7) 25 (39.7) albumin, duration of surgery, dosage of sufentanil, and Drinking 0.705 intraoperative blood loss relatively differed (0.05< P<0.10) No 90 (81.1) 134 (79.3) 53 (84.1) among the 3 groups. Yes 21 (18.9) 35 (20.7) 10 (15.9) On the basis of the results of the univariate analyses, sex, Surgical 0.722 age, height, weight, preoperative albumin, history of diabetes history No 83 (74.8) 120 (71.0) 44 (69.8) and hypertension, usage of VATS, duration of surgery, usage Yes 28 (25.2) 49 (29.0) 19 (30.2) of spreader, duration of using spreader, dosage of sufentanil, Notes: continuous variables are presented as the mean and the standard and intraoperative blood loss were included in an initial deviation, mean±sd. Categorical variables are presented as the number, cumulative logit model to identify the independent influ- with the percentage in parentheses, frequency (%). NRS, numerical rating encing factors of the intensity of CPTP (intensity order, scale. NRS, 0⟶1–3⟶4-). After model refinement, the history of diabetes, usage of VATS, and intraoperative blood loss remained. Table 3 shows the patients with diabetes CPTP is a highly prevalent complication following (OR �0.32, 95% CI: 0.14, 0.76) and usage of VATS thoracic surgery. )e incidence of CPTP has been investi- (OR �0.47, 95% CI: 027, 0.82) favored a lower intensity of gated for decades and has been estimated between 8% and CPTP, whereas more intraoperative blood loss (OR �1.09, over 80% [8, 9, 13–17]. One difficulty arises in comparing the 95% CI: 1.00, 1.19) favored a higher intensity of CPTP. incidence of CPTP among related studies because of dif- ferent definitions used. Two previous studies were con- ducted in the United States [18] and China [8]. )e United 4. Discussion States study estimated the incidence of CPTP at 3 months to In this study, the incidence of CPTP was estimated to be be 34.3% which is noticeably lower than the current study 67.6% in Chinese lung tumor patients after thoracic surgery, result; however, the Chinese study reported the incidence of 70.8% in benign patients, and 63.5% in malignant patients. 64.5% which is similar to this study. )is might be due to the Patients with diabetes and the use of VATS could reduce the different definitions of pain between the two previous intensity of CPTP; by contrast, the increasing amount of studies. In the Chinese study, patients reported persistent intraoperative blood loss could increase it. and intense discomfort after surgery, such as acid distension Number of CPTP patients 4 Journal of Healthcare Engineering P=0.147 43.2% 48.6% 33.3% 0 1-3 4- NRS levels Benign Malignant Figure 2: Distribution of the properties of tumor across the 3 levels of NRS among lung tumor patients. Notes: P �0.147, the result of Kruskal–Wallis test. NRS, numerical rating scale. Table 2: )e perioperative information of lung tumor patients with thoracic surgery according to the three levels of NRS scores. Items 0, n �111 1–3, n �169 4–, n �63 P ASA physical status 0.212 I 60 (54.1) 109 (64.5) 37 (58.7) II 51 (45.9) 60 (35.5) 26 (41.3) Preoperative albumin (g) 46.55±3.53 46.08±4.17 45.03±4.26 0.075 History of diabetes 0.007 No 96 (86.5) 163 (96.4) 59(93.7) Yes 15 (13.5) 6 (3.6) 4 (6.3) History of hypertension 0.028 No 90 (81.1) 155 (91.7) 53 (84.1) Yes 21 (18.9) 14 (8.3) 10 (15.9) Type of surgery 0.419 Wedge excision 30 (27.0) 60 (35.5) 17 (27.0) Lobectomy 74 (66.7) 93 (55.0) 39 (61.9) Others 7 (6.3) 16 (9.5) 7 (11.1) VATS 0.003 No 14 (12.6) 29 (17.2) 21 (33.3) Yes 97 (87.4) 140 (82.8) 42 (66.7) Duration of surgery (≥4hrs) 0.096 No 95 (85.6) 130 (76.9) 46 (73.0) Yes 16 (14.4) 39 (23.1) 17 (27.0) Use of spreader 0.013 No 96 (86.5) 138 (81.7) 43 (68.3) Yes 15 (13.5) 31 (18.3) 20 (31.7) Intraoperative blood loss (100ml) 1.00 (1.00) 1.00 (1.00) 1.00 (1.50) 0.073 Sufentanil (mg) 0.04 (0.02) 0.04 (0.02) 0.03 (0.02) 0.068 Remifentanil (mg) 1.50 (0.75) 1.50 (1.00) 1.50 (0.85) 0.308 Intercostal nerve block 0.929 No 99 (89.2) 150(88.8) 55 (87.3) Yes 12 (10.8) 19 (11.2) 8 (12.7) Postoperative hospital stay (days) 8.56±3.67 8.08±2.57 8.43±3.34 0.657 Postoperative morphine use (times) 0 (1.00) 0 (1.00) 0 (1.00) 0.115 Duration of drainage (≥4days) 0.428 No 72 (64.9) 112 (66.3) 36 (51.7) Yes 39 (35.1) 57 (33.7) 27 (42.9) Postoperative antibiotic use (days) 6.37±2.48 6.08±2.26 6.62±3.18 0.499 Notes: continuous variables are presented as the mean and the standard deviation, mean±sd. Categorical variables are presented as the number, with the percentage in parentheses, frequency (%). median (interquartile range, IQR). NRS, numerical rating scale; ASA, American Society of Anesthesiologists; VATS, video-assisted thoracoscopic surgery. Number of patients Journal of Healthcare Engineering 5 P=0.106 0 1-3 4 NRS levels Figure 3: Distribution of the using time of spreader across 3 levels of NRS among lung tumor patients (n �66). Notes: P �0.106, the result of Kruskal–Wallis test. Abbreviations: NRS, numerical rating scale. Table 3: Cumulative logit regression results of intensity of CPTP influencing factors in lung tumor patients following thoracic surgery. Items Coefficient Ordinal OR (95% CI) P History of diabetes −1.138 0.32(0.14, 0.76) 0.009 VATS −0.755 0.47(0.27, 0.82) 0.008 Intraoperative blood loss (100ml) 0.089 1.09(1.00, 1.19) 0.044 Notes: intensity CPTP order: NRS 0<1–3<4. Independent variables of baseline initially were included in the model but subsequently removed because of nonsignificance: sex, age, height, weight, preoperative albumin, history of hypertension, duration of surgery, usage of spreader, duration of using spreader and dosage of sufentanil. CPTP, chronic postthoracotomy pain; VATS, video-assisted thoracoscopic surgery; OR, odds ratio; 95% CI, 95% of confidence interval. and anesthesia, which was judged as pain, which was ana- by the aspects of diabetic patients. As known that diabetic logue to our study and might differ from the study in the peripheral neuropathy (DPN) is one of the complications of United States. diabetes as well as painful diabetic peripheral neuropathy An additional lack of comparability arises from the types (PDPN) and non-PDPN, the mechanisms of DPN and of patients and surgeries employed. A study conducted in PDPNs are still unknown [22–25]. Nevertheless, the pain Korea [15] reported an incidence of CPTP in patients with sensory of patients with neuropathy may be classified into 3 patterns, namely, positive pattern, negative pattern, and no traumatic multiple rib fractures of 52.3%. Moreover, a previous study [19] found that of 27% in patients after symptoms at all. [23]. )e positive pattern indicates in- creased sensory perception, which could explain the reason VATS. Regardless of the different definitions and types of patients, Bayman and Brennan [5] conducted a systematic diabetes is the risk factor of CPTP. )us, the protective effect review and demonstrated that the incidence of CPTP just on CPTP of diabetes could be due to the negative pattern following thoracotomy was 58% (ranged from 31% to 96%) which means numbness or sensory loss. Another point at 3 months, which is slightly lower than current study result. worth noting is that, in our univariate analysis, the patient However, Kinney et al. [10] estimated a rate of CPTP of 68% with hypertension was also a significant protective factor of in patients who underwent thoracotomy, which was similar CPTP, which is similar to a previous study [17], although it to our result although VATS and thoracotomy were both was removed from the final cumulative logit model because employed in the current study. )is phenomenon indicates of nonsignificance. Furthermore, Sacco et al. [26] reported that, with the progress of hypertension, the pain sensory the complexity of the incidence of CPTP, which may be influenced by not only types of patients and surgeries but would increase first and then decrease in patients suffering from chronic pain. )is phenomenon might suggest another also some potential factors such as cultures [20] or pain management [21]. potential explanation of the effect of diabetes on CPTP. An interesting finding of the current study is that pa- VATS is an alternative approach for lung surgery which tients with diabetes were identified as an independent is considered to be less tissue trauma and shorter recovery protective factor of CPTP by multivariate model. According [27–31]. VATS as a minimally invasive approach is expected to our literature review, numerous researches have studied to reduce postoperative pain; however, the relationship on CPTP or diabetes; however, only few studies [6, 8, 17] between VATS and CPTP is still ambiguous. Some of the reported the association between CPTP and diabetes. Wang relative studies reported that the rates of CPTP in VATS and et al. [8] and Kar et al. [6] found that patients with diabetes thoracotomy showed no difference [32–35], and meanwhile, others [16, 30, 31, 36] found that VATS was a protective was an independent risk factor of CPTP which was contrary to the finding of this study. )is dilemma might be explained factor of CPTP, which is consistent with our result. One of Duration of using spreader (hrs) 6 Journal of Healthcare Engineering related departments need to increase policy support in both the reasons for the different conclusions might be due to the time of interview at different postoperative days. A non- physical and physiological aspects, especially for patients with risk factors. significant result study interviewed patients at an average of 22 months after surgeries [32], compared with others ranging from 3 [31] to 12 [30] months. )is phenomenon Data Availability might suggest that, with the recovery process, the differences in the rate of CPTP at VATS and thoracotomy are elapsing. )e datasets used and analyzed during the current study are Other reasons might be the different types of patients and available from the corresponding author upon reasonable sample size of the study. request. Under the control of 12 pre-, intra-, and postoperative variables, the increasing amount of intraoperative blood loss Conflicts of Interest is identified as an independent risk factor of the intensity of CPTP, which indicates that no matter VATS or thoracot- )e authors declare that they have no conflicts of interest. omy, decreasing the amount of intraoperative blood loss would relief the chronic postoperative pain. Similarly with References this study, Homma et al. [7] detected intraoperative blood loss was a risk factor of neuropathic pain via univariate [1] M. Cao and W. Chen, “Epidemiology of lung cancer in China,” oracic Cancer, vol. 10, no. 1, pp. 3–7, 2019. analysis, but it was subsequently removed because of non- [2] F. R. Hirsch, G. V. Scagliotti, J. L. Mulshine et al., “Lung significance in the final logistic regression model. 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Journal of Healthcare Engineering – Hindawi Publishing Corporation
Published: Feb 24, 2022