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Федеральное государственное бюджетное учреждение науки
"Институт токсикологии Федерального медико-биологического агентства"
(ФГБУН ИТ ФМБА России)

Институт теоретической и экспериментальной биофизики Российской академии наук.

ООО "ИЦ КОМКОН".




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199406, Санкт-Петербург, ул.Гаванская, д. 49, корп.2

ISSN 1999-6314

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ТОМ 2, СТ. 33 (стр. 154) // Июль, 2001 г.

ПУЛЬМОНОЛОГИЯ




Cryoanalgesia in thoracic surgery

Cryosurgery in pulmonology



CRYOANALGESIA IN THORACIC SURGERY

M.O. Maiwand
Harefield Hospital, Harefield, UB9 6JH, United Kingdom

Introduction: The pain after thoracotomy can be very intense and can lead to severe postoperative complications. Several methods are currently employed to provide relief of post-thoracotomy pain. Each of the methods, however, is associated with specific disadvantages and side effects. By providing adequate analgesia it is possible to improve respiratory function, allow compliance with intensive physiotherapy and prevent complications. Results obtained in a study of 600 patients by the author, published in the Journal of Thoracic and Cardiovascular Surgery, showed a mean duration of analgesia of 27 days with only 7% of patients reporting severe postoperative pain.
Cryoanalgesia, localised freezing of intercostal nerves, has been reported to have variable effectiveness and an incidence of long-term cutaneous sensory changes. In conjunction with Beijing University, China, we carried out an animal study to assess the reversibility of histological changes induced by cryoanalgesia and also a prospective randomised trial to compare the effectiveness of cryoanalgesia with conventional analgesia (parenteral opiates).

Methods: In six anaesthetised dogs, intercostal nerves were exposed to a varying duration of cryo-application (30s, 60s, 90s & 120s). The nerves were biopsied and examined histologically at regular intervals over the following six months. In the clinical study, two hundred consecutive patients undergoing thoracotomy were randomised to cryoanalgesia and conventional (parenteral opiates) analgesia groups. In the cryoanalgesia group, intercostal nerves (one at the level of the incision, one cranial and two caudal) received a 60s application of a cryoprobe (approximately -50°C). Postoperative pain scores, respiratory function tests and use of opiate analgesia were measured for the two groups.

Results: Following application of the cryoprobe, degeneration and fragmentation of the axons was evident with associated inflammatory changes. As the endoneurium remained intact, axonal regeneration took place after the resolution of axonal swelling. Over the course of weeks, recovery of the intercostal nerve occurred and was complete after one month for the 30 & 60s groups. For nerves exposed to longer durations of cryoanalgesia, the time taken for complete recovery was proportionally increased. For the clinical study, there was a statistically significant (p<0.05) improvement in post-operative pain scores and use of opiate analgesia and an improvement (p>0.05) in respiratory function tests for patients in the cryoanalgesia group. The previously suggested cutaneous sensory changes resolved within six months with complete restoration of function.

Methods: In six anaesthetised dogs, intercostal nerves were exposed to a varying duration of cryo-application (30s, 60s, 90s & 120s). The nerves were biopsied and examined histologically at regular intervals over the following six months. In the clinical study, two hundred consecutive patients undergoing thoracotomy were randomised to cryoanalgesia and conventional (parenteral opiates) analgesia groups. In the cryoanalgesia group, intercostal nerves (one at the level of the incision, one cranial and two caudal) received a 60s application of a cryoprobe (approximately -50°C). Postoperative pain scores, respiratory function tests and use of opiate analgesia were measured for the two groups.

Results: Following application of the cryoprobe, degeneration and fragmentation of the axons was evident with associated inflammatory changes. As the endoneurium remained intact, axonal regeneration took place after the resolution of axonal swelling. Over the course of weeks, recovery of the intercostal nerve occurred and was complete after one month for the 30 & 60s groups. For nerves exposed to longer durations of cryoanalgesia, the time taken for complete recovery was proportionally increased. For the clinical study, there was a statistically significant (p<0.05) improvement in post-operative pain scores and use of opiate analgesia and an improvement (p>0.05) in respiratory function tests for patients in the cryoanalgesia group. The previously suggested cutaneous sensory changes resolved within six months with complete restoration of function.

Conclusions: We suggest that cryoanalgesia be considered as a simple, inexpensive, long-term form of post-thoracotomy pain relief, which does not cause any long-term histological damage to intercostal nerves.

CRYOSURGERY IN PULMONOLOGY

M.O. Maiwand
Harefield Hospital, Harefield, UB9 6JH, United Kingdom

Lung cancer is the leading cause of cancer death in the world and affects 900,000 people yearly. It is rapidly disabling and has a very poor survival rate of only 10-13% over 5 years. Surgical resection offers the best possibility of a cure but unfortunately, most patients (over 80%) are at such an advanced stage that the disease is deemed inoperable and symptom palliation is the only option. Around 30% of these inoperable patients present with obstruction of the central airway which itself leads to significant morbidity and mortality. The standard methods of treatment of obstruction caused by lung cancer have been radiotherapy or chemotherapy which have limited effectiveness in reopening the blocked lumen and may have a damaging effect on the surrounding healthy tissue. They also have the disadvantage that patients may not be able to tolerate repeated courses of treatment. Endobronchial cryosurgery was pioneered in the UK at Harefield Hospital, in 1986, and since then over 800 patients have been treated. Cryosurgery is one of a number of techniques that can be used to reopen obstructed tracheobronchial lumen for patients with inoperable tumours. The alternatives include laser treatment, diathermy and stent placement.
In a recent study in this hospital, we have found significant improvements in symptom quantification, performance status and respiratory function tests for patients treated with cryosurgery. These patients were referred for cryosurgery because they were considered inoperable on the basis of the position and stage of their tumour, their poor performance status or respiratory function. The study comprised consisted of 370 consecutive patients with histologically proven malignant carcinoma, treated between 1995 and 2000. The mean age was 68 years with around two thirds of patients over 65 and a male to female ratio of 1.8:1. Patients received an average of 2.5 cryotreatments. There was a high proportion of patients with advanced disease (92% at stage III or IV). Patient histology was as follows, squamous cell carcinoma 67.8%, adenocarcinoma 14.8%, small cell 10.0%, large cell 1.3% and undifferentiated non-small cell 6.1%. The results showed improvements in symptom quantification for dyspnoea, cough, haemoptysis and chest pain (65%, 68%, 82% and 59% respectively) and also improvements in Karnofsky and WHO performance status. Respiratory function tests showed improvements from a mean of 1.26 to 1.43 litres for forced expiry volume in one second (FEV1) and from a mean of 1.88 to 2.13 litres for forced vital capacity (FVC). The median survival (Kaplan-Meier) for this elderly, late stage group of patients was 12.9months.
Cryosurgery has also been used for the treatment of a number of benign and low malignancy lesions including carcinoid tumours, granulation tissue following heart/lung transplant [34], amyloidosis [35], tracheobronchopathia osteochondroplastica (TBOCP), sarcoid, lipoma, polyps, post-intubation tubal stenosis, leiomyoma, haemangioma and Wegner's granulomatosis.
The use of cryosurgery in the tracheobronchial area has been proven to provide a safe, rapid and effective method for the restoration of patency in blocked tracheobronchial lumen. It improves symptoms, respiratory function and also quality of life. The technique is easy to perform, economical, has minimal complications and is well tolerated by the patient.

В кн.: Достижения криомедицины.СПб.Изд-во "Наука", 2001, С.1-5-108.

Страница 154вверх (Пульмонология)

Свидетельство о регистрации сетевого электронного научного издания N 077 от 29.11.2006
Журнал основан 16 ноября 2000г.
Выдано Министерством РФ по делам печати, телерадиовещания и средств массовых коммуникаций
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