Intercostal muscle flap and intracostal suture: is two better than one?

Abstract

We read with great interest the article by Sapkota and colleagues. 1 Their study, a randomized clinical trial, included 48 patients over a period of 15 months. Twenty-five patients were included in a control group, and underwent pericostal suture of intercostal space by the classic technique; 23 patients formed the study group, with suture of the intercostal space by an intracostal technique. Also, a flap of intercostal muscle at the start of the operation was performed only in the study group. Therefore, in the study group two combined techniques were used for reducing post-thoracotomy pain. Both techniques and their effectiveness have been described by Cerfolio and colleagues, 2,3 as reflected in the article by Sapkota. Since then, several studies have examined their role in the control of acute and chronic post-thoracotomy pain. In a systematic review published by our group, 4 we analyzed the evidence so far, and we concluded that the combination of an intercostal flap to prevent nerve compression by the rib spreader, with an intracostal suture technique, is significantly more effective in the control of immediate and long-term pain, compared to the classic pericostal suture (level of evidence grade A). This conclusion is supported by the work published by Sapkota and colleagues. 1 However, the completion of an intercostal flap for applying a separator combined with an intracostal suture provides no improvement in the control of acute or subacute pain regarding the intracostal suture technique without an intercostal flap (level of evidence grade A).Based on the available evidence, we ask if two is better than one? In any case, it seems to us to be a job very well done, with results and conclusions consistent and concordant with published evidence. With this contribution, the importance of the techniques for protection of intercostal nerves in preventing post-thoracotomy pain is strengthened.

Combination of intracostal sutures with muscle flap to decrease post thoracotomy pain: A single blinded randomized clinical trial

“…Allama et al evaluated ICM flap role in reduction of post thoracotomy pain, and results showed that ICM flap combined with intracostal sutures provides rapid, safe and much effective technique, compared to other techniques 17. On the other hand, Gracia et al showed that the long term efficacy of intercostal muscle flap in post thoracotomy pain improvement was much more significant 18. However, Wu et al showed that a combination of intracostal suture with intercostal muscle flap may not necessarily lead to better post-thoracotomy pain control than using intercostal suture alone 19.…”