Bilateral Thoracoscopic

This page answers the following FAQs regarding this procedure:



 
What is Bilateral Thoracoscopic Splanchnotomy?
Who may benefit from this procedure?
What does the operation involve?
What are the complications of this operation?
What to expect after the operation?
What are the long-term results?
 
What is Bilateral Thoracoscopic Splanchnotomy?

This is a 'keyhole' operation hat involves the division of the nerves on both sides of the chest that carry the pain sensation from the abdomen (pancreas, liver, gallbladder, stomach) to the brain. These nerves run along the vertebral spine and can be easily seen with a fine 5-mm camera placed in the chest.
 
Who may benefit from this procedure?

Patients who suffer from intractable and severe chronic abdominal pain that requires very strong painkillers, such as morphine, may benefit from this operation. The pain killers might not have been quite effective in controlling the pain, or it may be that very high doses of morphine (or other similar pain killers) were needed to control the pain, and that such high doses had some considerable side effects. The patients who might benefit from this operation may fall into one of three categories:

 
Patients with chronic inflammation of the pancreas gland (chronic pancreatitis). These patients tend to be young and the pain could be incapacitating. Many might have previously received one or more injections in the back (coeliac plexus block) to relieve the pain with short-lived partial response only.

 
Patients with advanced upper abdominal cancer causing severe abdominal pain, such as patients with pancreatic cancer, gallbladder cancer, gastric cancer or liver cancer. It is important to select these patients carefully and in conjunction with the Pain and Palliative Care teams, as some may have a very short life expectancy and may not be fit for a general anaesthetic.

 
Patients with benign and multiple liver cysts (polycystic liver disease).
 
What does the operation involve?

The operation is performed under general anaesthesia, and involves 2 or 3 cuts, 5-mm each, on the back of either side of the chest and the insertion of a cannula through which gas (carbon dioxide) is introduced into one side of the chest at a time in order to partially collapse the lung. A camera is introduced into the chest cavity and the nerves are readily identified running along the vertebral column. The nerves are carefully picked and divide with a diathermy hook or a special ultrasonically-activated shears. The anaesthetist then inflates the lung and the gas is released from the chest. No chest drains are necessary, and we do not routinely request a chest X-ray after the operation. The wounds are closed using absorbable sutures placed under the skin. Most patients will stay in hospital overnight, but some may be discharged home on the evening of the surgery.
 
What are the complications of this operation?

Complications are very uncommon, and we have encountered none. However, retention of air into the chest (pneumothorax) or bleeding into the chest (haemothorax) may occur and require the insertion of a chest tube. Failure of the lung to expand fully is another potential problem that may lead to a chest infection. Rarely, one may have to abandon the procedure if there were extensive adhesions between the lung and the chest wall (ribs) that might have been caused by previous chest infections.
 
What to expect after the operation?

In approximately 80% of the patients, the effect of surgery on the abdominal pain is immediate and becomes apparent once the patient has returned to the ward from the operating theatre. The previous dose of opiate painkiller is then reduced by 20-25%, and the patient will be asked to continue to reduce the dosage by a further 20-25% each week if tolerated. Most patients will be allowed home the following day, though some may be discharged from hospital on the evening of the operation.

Some patients may experience shoulder-tip pain for a day or so after the operation. This is a false pain, as it simply reflects some irritation in the chest from the introduction of the gas (carbon dioxide) at the time of the operation. We routinely try to prevent this by instilling a local anaesthetic into the chest cavity at the end of the procedure.
  
What are the long-term results?

The large majority of patients with cancer may expect a lasting effect with reduction or discontinuation of opiate painkillers. However, the pain may start to recur in 50% of the patients with chronic pancreatitis some months or years (an average of 5 years) after the operation and requires a return to, or an increase of the dose of the opiate painkillers.
  
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