Preoperative use of hypnotic medication, the thoracotomy approach, and duration of surgery ≥2.5 hours are associated with increased risk of neuropathic pain after thoracic surgery. The complete VATS approach could decrease the incidence of postoperative neuropathic pain, regardless of the duration of surgery.

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Background: To assess the potential of the ultrasonographic sliding lung sign to detect severe intrathoracic adhesions before surgery. Methods: This was a prospective, single-center, observational study including all patients aged 20-89 years undergoing elective thoracic surgery. Patients with pneumothorax, pyothorax, hemothorax, chylothorax, and hydrothorax were excluded. We recorded the ultrasound sliding lung sign, surgical characteristics, and follow-up parameters: past medical history, respiratory function, chest X-ray findings, and computed tomography (CT) findings. Severe intrathoracic adhesion was defined as the need for adhesiolysis requiring more than 30 minutes. Results: A total of 168 patients consented to participate. All 15 patients without the sliding lung sign had hard severe adhesions [specificity 100%, sensitivity 88.2%, positive predictive value (PPV) 100%, negative predictive value (NPV) 98.7%, and area under curve (AUC) 0.94]. There were two false-negative results, both of which were soft adhesions. Although blunting of the costophrenic (CP) angle, CT findings, past medical history, and restrictive lung disease were identified as significant risk factors of severe intrathoracic adhesion, all areas under the curve were low (0.71, 0.71, 0.69, 0.61, respectively). Thoracotomy frequency, intraoperative bleeding, operative time, and postoperative hospitalization were significantly greater in these patients than in those with non-severe adhesions. Conclusions: The ultrasound sliding lung sign could be used to predict severe intrathoracic adhesions before surgery. Preoperative confirmation of the ultrasound sliding lung sign is important for planning surgical approaches and implementing appropriate safety management.

Background: Manual aspiration as the initial management of a large pneumothorax in a clinically stable patient has been reported to be safe and effective. However, the effect with smaller needles, the number of aspiration, the indication other than spontaneous pneumothorax and failure factors are unknown. We assessed the effectiveness and failure risk factors of manual aspiration up to three using a 20-or 22-gauge (G) needle in patients with a large, clinically stable pneumothorax.Methods: We included 107 clinically stable patients with large pneumothorax. Patients who were unstable, required a ventilator, underwent chest tube drainage or had an observed small pneumothorax, bilateral pneumothorax, hemopneumothorax, or postoperative pneumothorax were excluded. Up to three aspirations were performed using 20-or 22-G intravenous needles. When the aspiration volume was ≥2,500 mL or lung expansion did not occur, a chest tube was placed. Results:The first aspiration was successful in 57 patients (53.3%), the second in 16 patients (59.3%), and the third in eight patients (80.0%). No patient experienced any obvious complications or required emergent hospitalization or surgery after aspiration. Aspiration failure was correlated with an inter-pleural distance >20 mm at the level of the hilum (odds ratio: 4.93; 95% confidence interval: 1.49-22.71; P=0.0075), spontaneous secondary pneumothorax (odds ratio: 3.11; 95% confidence interval: 1.14-8.76; P=0.027), and ≤24 h from onset to presentation (odds ratio: 2.95; 95% confidence interval: 1.12-8.26; P=0.028). There were no significant differences in intrathoracic pressure after aspiration or plasma factor XIII levels between patients with resolved and persistent pneumothorax.Conclusions: Manual aspiration up to three times using a small needle might be one of a treatment option in clinically stable patients with any large pneumothorax. Aspiration failure was correlated with an inter-pleural distance >20 mm at the level of the hilum, spontaneous secondary pneumothorax, and ≤24 h from onset to presentation.