Interactive CardioVascular and Thoracic Surgery Advance Access published December 3, 2014

Is uniport thoracoscopic surgery less painful than multiple port approaches? Rebekah Younga, Philip McElnayb, Rebecca Lesliec and Douglas Westb,* a b c

Medical School, University of Bristol, Bristol, UK Department of Thoracic Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK Department of Anaesthesia, University Hospitals Bristol NHS Foundation Trust, Bristol, UK

* Corresponding author. University Hospitals Bristol NHS Foundation Trust, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK. Tel: +44-117-3423522; fax: +44-117-3423132; e-mail: [email protected] (D. West) Received 14 August 2014; received in revised form 15 October 2014; accepted 28 October 2014

Abstract A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was ‘In patients undergoing Video-Assisted Thoracoscopic Surgery (VATS), does a uniport (single-port) or multiport technique convey benefit in terms of postoperative pain?’ Altogether, 255 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studies, study type, relevant outcomes and results of these tables are tabulated. All the available evidence is from small, non-randomized studies. Many were retrospective and methodologically weak. Most studied minor thoracic surgical procedures and a few compare the two approaches in major pulmonary resections. One of the studies compared pain at 24 h for uniport [mean Visual Analogue Scale (VAS) >4.4] and three-port VATS (mean VAS 6.2), for different procedures including lung biopsy and surgery for pneumothorax (P = 0.035). Another study compared pain in the first 36-h post-sympathectomy and found mean pain scores of 0.8 in the uniport group and 1.2 in the two-port group (P = 0.025). Six studies exclusively compared the VAS between uniport and three-port VATS for primary spontaneous pneumothorax. Two studies found no significant difference in pain scores and four found a statistically significant reduction in early postoperative pain scores. One study found that pain scores were similar for lung volume reduction surgery. Two studies compared the mean VAS and morphine use between uniportal and multiportal lobectomies; however, there were no statistically significant differences. From the papers identified in our search, we conclude that uniport VATS may have a small clinical effect in reducing postoperative pain, with the majority of papers looking at the first 72 h following surgery. Often the VAS score was only improved in the uniport patients by 1–2 points, and the studies did not find statistically significant results throughout their investigations, especially when looking at follow-up pain scores. Around one-third of the chosen papers did not find any statistically significant results. Further studies are needed before single-port can be recommended as less painful than multiport thoracoscopic surgery. Keywords: Thoracic surgery • Video-assisted • Outcome assessment • Analgesia

INTRODUCTION A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].

his procedure. You are aware that some units carry out uniport VATS procedures but are not sure about the evidence for this approach. You decide to review the literature in order to decide if there is a postoperative benefit in terms of pain.

THREE-PART QUESTION

SEARCH STRATEGY

In [ patients undergoing either minor or major Video-Assisted Thoracoscopic procedures] does a [uniport instead of a multi-port technique] convey benefit in [ post-operative pain]?

Medline 1950 to July 2014 using OVID interface: [Thoracic Surgery, Video-Assisted/] OR [VATS.mp.] OR [thoracoscop*.mp.] OR [video-assisted thoracoscopic surgery.mp.] AND

CLINICAL SCENARIO A 45-year old man attends clinic to discuss lung biopsy. These operations are carried out in your hospital using a three-port VATS technique. His relative had an abdominal operation carried out recently via one ‘keyhole incision.’ He asks if this is an option for

[uni-port or uniport.mp.] OR [single-port or singleport.mp.] OR [single-incision or single incision.mp.] AND [ pain.mp or Pain/] OR [VAS or visual analogue score.mp.] OR [NRS or numerical rating scale.mp.] OR [VDS or visual descriptor scale.

© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

BEST EVIDENCE TOPIC

BEST EVIDENCE TOPIC – THORACIC

Interactive CardioVascular and Thoracic Surgery (2014) 1–5 doi:10.1093/icvts/ivu391

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R. Young et al. / Interactive CardioVascular and Thoracic Surgery

Table 1: Best evidence papers Author, date and country Study type (level of evidence)

Patient group

Outcomes

Key results

Comments

Chen et al. (2011), J Cardiothorac Surg, Taiwan [2]

n = 30, surgery for primary spontaneous pneumothorax

VAS score (0–10)

Pain at 24 h: Uniport: 4.50 ± 0.70 Three-port: 4.95 ± 0.39 (P = 0.032)

Pain was statistically significantly lower in the uniport group compared with the three-port group at 24 h

10 patients: uniport Prospective cohort study (level IIb)

Pain at 48 h: Uniport: 4.20 ± 0.78 Three-port: 4.25 ± 0.58 (P = 0.088)

20 patients: three-port

Results at 48 and 72 h were not significant; however, there was a trend towards lower pain scores in the uniport group

Pain at 72 h: Uniport: 3.30 ± 0.48 Three-port: 3.55 ± 0.60 (P = 0.256) Wu et al. (2013), J Cardiothorac Surg, Taiwan [3]

n = 21, diaphragm plication

Prospective cohort study (level IIb)

10 patients: uniport approach

Mier et al. (2013), Surg Endosc, Spain [4]

n = 20, procedures included 11 lung biopsies, 6 pneumothorax procedures, 2 mediastinal cyst excisions and 1 catamenial pneumothorax procedure

Prospective comparative study (level IIb)

VAS score (0–10)

11 patients: two-port approach

Mean at 24 h: Uniport: 3.85 Two-port: 4.1 (P = 0.57)

No significant difference in results

Mean at 36 h: Uniport: 3.5 Two-port: 3.3 (P = 0.48) VAS score (0–10)

Mean at 24 h: Uniport: 4.4 ± 1.7 Three-port: 6.2 ± 1.4 (P = 0.035)

Statistically significant results showing patients undergoing uniport VATS had less postoperative pain than those patients undergoing three-port VATS

VAS score (0–10)

Pain at 24 h: Uniport: 4.0 Three-port: 4.4 (P = 0.135)

Postoperative pain was significantly lower in the uniport group compared with the three-port group at 72 h; however, pain scores were similar in the two groups at 24 and 48 h

10 patients: three-port VATS 10 patients: uniport VATS

Chen et al. (2012), J Cardiothorac Surg, Taiwan [5]

n = 62, surgery for primary spontaneous pneumothorax 26 patients: three-port VATS

Retrospective cohort study (level IIb)

Pain at 48 h: Uniport: 3.2 Three-port: 3.6 (P = 0.084)

36 patients: uniport VATS

Pain at 72 h: Uniport: 2.5 Three-port: 2.9 (P = 0.008) Salati et al. (2007), Interact CardioVasc Thorac Surg, Italy [6]

n = 51, surgery for primary spontaneous pneumothorax

Telephone interviews: Numeric pain scale (0–10)

Pain scale: Uniport: 0.6 Three-port: 1.3 (P = 0.24)

23 patients: three-port VATS Retrospective cohort study (level IIb)

Means for follow-up of at least 6 months:

28 patients: uniport VATS

McGill pain questionnaire: (1) at rest, (2) on coughing, (3) arm pain

Results were not significant; however, there was a trend towards lower pain scores on the numeric pain scale and McGill questionnaire in the uniport group. In addition, a greater percentage of this group returned to normal activity

McGill at rest: Uniport: 0.15 Three-port: 0.56 (P = 0.28) McGill on cough: Uniport: 0.15

Continued

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BEST EVIDENCE TOPIC

R. Young et al. / Interactive CardioVascular and Thoracic Surgery

Table 1: (Continued) Author, date and country Study type (level of evidence)

Patient group

Outcomes

Key results

Comments

Three-port: 0.33 (P = 0.38) McGill arm pain: Uniport: 0.31 Three-port: 0.78 (P = 0.19)

Chen et al. (2009), Chin Med J, China [7]

% Return to normal activity

Normal activity: Uniport: 96% Multiport: 79% (P = 0.069)

Inpatient pain scores (0–4) collected every 6 h for 36 h

Mean pain score: Uniport: 0.8 ± 0.5 Two-port: 1.2 ± 0.6 (P = 0.025)

The mean inpatient pain scores were significantly lower in the uniport group compared with the biportal group

25 patients: biportal VATS

% patients with residual pain during the first 3 weeks (via telephone interview)

% Residual pain: Uniport: 20% Biportal: 32% (P = 0.366)

More patients experienced residual pain in the biportal group, but this was not statistically significant

n = 40, surgery for primary spontaneous pneumothorax

VAS score (0–10)

Pain day 0: Uniport: 4.1 ± 1.7 Three-port: 4.8 ± 2.2 (P = 0.26)

No significant difference in postoperative pain between those patients undergoing uniport and three-port VATS

Pain day 1: Uniport: 3.2 ± 1.4 Three-port: 2.8 ± 1.4 (P = 0.33)

There was a non-significant trend towards less frequent use of intravenous analgesia in the uniport group

n = 45, sympathectomy for palmar hyperhidrosis 20 patients: uniport VATS

Retrospective cohort study (level IIb)

Yang et al. (2012), Surg Endosc, South Korea [8]

13 patients: three-port VATS Retrospective cohort study (level IIb)

27 patients: uniport VATS

Pain day 2: Uniport: 2.7 ± 1.0 Three-port: 2.6 ± 1.1 (P = 0.61)

Tamura et al. (2013), J Cardiothorac Surg, Japan [9] Retrospective analysis (level IIb)

n = 37, surgery for primary spontaneous pneumothorax, peripheral lung nodules and thymic tumours 19 patients: uniport VATS 18 patients: three-port VATS

Number of requests for postoperative intravenous analgesia

Analgesics: Uniport: 2.8 ± 1.0 Three-port: 3.5 ± 2.5 (P = 0.23)

VAS score (0–10)

Pain on Day 0: Uniport: 4.955 ± 0.38 Three-port: 6.44 ± 0.39 (P = 0.012)

Postoperative pain scores on Days 0, 1 and 3 were significantly higher in those patients undergoing three-port VATS

Pain on Day 1: Uniport: 2.74 ± 0.34 Three-port: 3.78 ± 0.35 (P = 0.039)

Patients undergoing three-port VATS tended to receive higher doses of analgesics, but this was not statistically significant

Pain on Day 3: Uniport: 1.32 ± 0.20 Three-port: 1.944 ± 0.21 (P = 0.037) Pain on Day 7: Uniport: 0.42 ± 0.18 Three-port: 0.83 ± 0.18 (P = 0.428) Pain on Day 14: Uniport: 0.26 ± 0.11 Three-port: 0.39

Continued

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R. Young et al. / Interactive CardioVascular and Thoracic Surgery

Table 1: (Continued) Author, date and country Study type (level of evidence)

Patient group

Outcomes

Key results

Comments

(P = 0.078)

Jutley et al. (2005), Eur J Cardiothorac Surg, UK [10]

n = 35, surgery for spontaneous pneumothorax 16 patients: uniport VATS

Retrospective cohort study (level IIb)

Socci et al. (2013), Interact CardioVasc Thorac Surg, UK [11]

Analgesic doses

Uniport: 0.89 ± 0.24 Three-port: 1.44 ± 0.94 (P = 0.119)

VAS score (0–4)

Median score: Uniport: 0.4 ± 0.5 Three-port: 0.8 ± 0.7 (P = 0.06)

Measured every hour for the first 12 h, then every 4 h till discharge

Max score: Uniport: 1.4 ± 0.9 Three-port: 2.6 ± 0.9 (P = < 0.001)

19 patients: three-port VATS

n = 24, lung volume reduction surgery

The uniport group had statistically significant lower maximum pain scores than the three-port group More patients in the three-port group reported chronic mild residual pain; however, this result was not significant

% Chronic mild residual pain (mean follow-up time 9.4 months for uniport and 32.1 months for three-port group)

Chronic pain: Uniport: 28% Three-port: 42% (P = 0.6)

Postop pain scores Days 1 and 2 and epidural use

Scores similar

No significant difference in results

VAS score 0–10

Median pain score in the first 24 h: Uniport: 0 Multiport: 0 (P = 0.65)

Patient-reported pain and morphine use in the first 24 h was low with both the uniport and multiport techniques

Morphine use (mg)

Median morphine use in the first 24 h: Uniport: 19 mg Multiport: 23 mg (P = 0.84)

VAS score (0–10)

Median pain score: Uniport: 2.6 Three-port: 4.2 (P < 0.05)

15 patients: three-port VATS Retrospective cohort study (level IIb)

9 patients: uniport VATS

McElnay et al. (2014) Eur J Cardiothorac Surg, UK [12]

n = 110 VATS lobectomy

Retrospective cohort study (level IIb)

95 patients: multiport VATS

Byun et al. (2013), Annual meeting ISMICS (conference abstract), South Korea [13]

n = 24, primary spontaneous pneumothorax

15 patients: uniport VATS

Postoperative pain was significantly lower in the single-port group

12 patients: uniport VATS 12 patients: three-port VATS

Case–control study (level III) VATS: video-assisted thoracoscopic surgery; VAS: Visual Analogue Scale.

mp.] OR [VNRS or visual numerical rating scale.mp.] OR [analges* or morphine or opiod* or opiate*.mp.]

SEARCH OUTCOME A total of 255 papers were found using the reported search. From these, 10 papers and 2 abstracts were identified that provided the best evidence to answer the question. These are presented in Table 1.

RESULTS No randomized trial evidence was found, but several comparative studies were identified. These were all relatively small, the largest study reporting 100 patients in total. Wu et al. [3] compared the VAS score at 24 and 36 h between uniport and two-port VATS procedures for diaphragm plication, but found no significant difference in either result.

R. Young et al. / Interactive CardioVascular and Thoracic Surgery

CLINICAL BOTTOM LINE Uniportal VATS may have a small effect on early postoperative pain, with just over half of the studies found showing significant reductions in VAS scores in the first days postoperatively. However, all the studies were small, non-randomized and unblinded, and therefore susceptible to various forms of bias. Not every study stated where the incisions were made, which is an important variable given that the number of intercostal nerves disturbed may affect the patient’s postoperative pain. Often the VAS score only differed by 1–2 points between groups. Given the subjective nature of these scores, the clinical significance is small. Higher quality prospective randomized studies are needed before single port can be recommended as less painful than multiport thoracoscopic surgery. Conflict of interest: none declared.

REFERENCES [1] Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–9. [2] Chen PR, Chen CK, Lin YS, Huang HC, Tsai JS, Chen CY et al. Single-incision thoracoscopic surgery for primary spontaneous pneumothorax. J Cardiothorac Surg 2011;6:58. [3] Wu HH, Chen CH, Chang H, Liu HC, Hung TT, Lee SY. A preliminary report on the feasibility of single-port thoracoscopic surgery for diaphragm plication in the treatment of diaphragm eventration. J Cardiothorac Surg 2013;8:224. [4] Mier JM, Chavarin A, Izquierdo-Vidal C, Fibla JJ, Molins L. A prospective study comparing three-port video-assisted thoracoscopy with the singleincision laparoscopic surgery (SILS) port and instruments for the video thoracoscopic approach: a pilot study. Surg Endosc 2013;27:2557–60. [5] Chen CH, Lee SY, Chang H, Liu HC, Hung TT, Chen CH. The adequacy of single-incisional thoracoscopic surgery as a first-line endoscopic approach for the management of recurrent primary spontaneous pneumothorax: a retrospective study. J Cardiothorac Surg 2012;7:99. [6] Salati M, Brunelli A, Xiume F, Refaia M, Sciarra V, Soccetti A et al. Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach. Interact CardioVasc Thorac Surg 2008;7:63–6. [7] Chen YB, Ye W, Yang WT, Shi L, Guo XF, Xu ZH et al. Uniportal versus biportal video-assisted thoracoscopic sympathectomy for palmar hyperhidrosis. Chin Med J 2009;122:1525–8. [8] Yang HC, Cho S, Jheon S. Single-incision thoracoscopic surgery for primary spontaneous pneumothorax using the SILS port compared with conventional three-port surgery. Surg Endosc 2013;27:139–45. [9] Tamura M, Shimizu Y, Hashizume Y. Pain following thoracoscopic surgery: retrospective analysis between single-incision and three-port video-assisted thoracoscopic surgery. J Cardiothorac Surg 2013;8:153. [10] Jutley RS, Khalil MW, Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005;28:43–6. [11] Socci L, Jones V, Malik M, Internullo E, Martin-Ucar A. Single-port video-assisted thoracic lung volume reduction surgery for emphysema: reducing surgical trauma does not compromise the procedure. Interact CardioVasc Thorac Surg 2013;17(suppl 1):S1–S62. [12] McElnay PJ, Molyneux M, Krishnadas R, Batchelor TJ, West D, Casali G. Pain and recovery are comparable after either uniportal or multiport videoassisted thoracoscopic lobectomy: an observation study. Eur J Cardiothorac Surg 2014; doi:10.1093/ejcts/ezu324. [13] Byun CS, Hwang JJ, Choi JH. Single-incision VATS bullectomy with suturelift method in primary spontaneous pneumothorax. In: Conference: 2013 Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery. ISMICS 2013 Prague Czech Republic, Conference Publication: (var.pagings). 8;145–6.

BEST EVIDENCE TOPIC

Mier et al. [4] compared the mean VAS at 24 h for uniport and three-port VATS, for different procedures including lung biopsy and surgery for pneumothorax. These results were significant, with a lower pain score for single incision of 4.4, against 6.2 for three-port VATs (P = 0.035). Chen et al. [7] looked at patients undergoing sympathectomy for palmar hyperhidrosis, and found that mean pain scores in the first 36 h postoperatively were 0.8 in the uniport group and 1.2 in the two-port VATS group (P = 0.025). In the uniport group, 20% of patients reported residual pain in the following 3 weeks, compared with 32% in the two-port group, but this later measurement was not significant. Tamura et al. [9] investigated patients undergoing thoracoscopic surgery for primary spontaneous pneumothorax, peripheral lung nodules and thymic tumours, and found that the mean VAS was significantly lower in those patients undergoing uniport VATS than three-port VATS on Days 0, 1 and 3 postoperatively. The study also demonstrated that patients undergoing three-port VATs tended to require a higher dose of analgesia than those undergoing uniport VATS, but this was not statistically significant. Several studies compared the VAS between uniport and three-port VATS for primary spontaneous pneumothorax. Yang et al. [8] compared the mean VAS at 0, 1 and 2 days postoperatively, as well as requests for IV analgesia, but no statistically significant difference was found. Chen et al. [5] found a statistically significant lower VAS at 72 h in the single-port group compared with three-port group (2.5 and 2.9, respectively, (P = 0.008)); however, the results were similar at 24 and 48 h postoperatively. A separate Chen et al. [2] study found that postoperative pain was significantly lower in the uniport group compared with the three-port group at 24 h, with scores of 4.5 and 4.95, respectively (P = 0.032). Scores at 48 and 72 h also followed this trend but were not significant. Jutley et al. [10] studied 35 patients undergoing pneumothorax surgery, and found a lower maximum VAS in the uniport group of 1.4 compared with 2.6 in the three-port group (P < 0.001). However, the median in-hospital VAS scores and those during long-term follow-up were not significantly different (P 0.06 and 0.6, respectively). Byun et al. [13] also found that the mean VAS was lower in the uniport group, 2.6 compared with 4.2 in the three-port group (P < 0.05). Salati et al. [6] also compared uniport and three-port VATS for primary spontaneous pneumothorax, but looked at the mean results of the patients’ Numeric Pain Scale and the McGill Pain Questionnaire recorded over a postoperative period of at least 6 months. The results were not significant; however, there was a trend towards lower postoperative pain scores in the uniport patients. This was the methodologically strongest paper identified, studying patients prospectively with a validated pain assessment tool, and continuing follow-up after discharge. Socci et al. [11] compared pain scores on Days 1 and 2 postoperatively between uniport and three-port VATS for lung volume reduction surgery, and found that scores were similar. McElnay et al. [12] compared VAS, morphine use and other postoperative outcomes with larger numbers of patients in either subgroup—15 uniport and 95 multiport. No difference was found in pain scores or morphine use between the groups.

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Is uniport thoracoscopic surgery less painful than multiple port approaches?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'In patients undergoing Video-Ass...
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