The Second Stage Thoracoplasty

The clinical reaction and the mental attitude of the patient, following the first and second stage of a paravertebral thoracoplasty, are contrasted, correcting the often accepted belief that the second stage is of less importance to the patient than the first.

From experience of twenty years it is concluded that the second stage is not tolerated as well as the first. There is a greater incidence of complications. Increased pain on coughing and on use of the arm requires more sedation. Respiration is more difficult, requiring an oxygen tent for a longer period. The wound heals more slowly and exhibits a greater tendency to either become infected, or to develop a non-purulent drainage, due to remaining bits of catgut not absorbed in the interval between the two stages and, because of incomplete re-establishment of circulation. Finally, the loss of vital capacity is greater.

Measures adopted to lessen the gravity of the second stage thoracoplasty consist of the following:

1. Increasing the interval between stages from ten or twelve days to eighteen or twenty-one days. This time shows improvement in appetite, diminished cough and allows much needed sleep and rest. Ambulation for a few days has an important influence on the circulation, general well-being, and, morale of the patient.

2. Feeding early, with special emphasis given to a diet high in protein content. Blood transfusions are added as needed and vitamin C is administered.

3. Combatting infection by use of penicillin.

4. Choosing an anesthetic which lessens complications. Intravenous sodium pentothal supplemented by paravertebral block with one per cent novacaine is recommended. A quiet induction, quick return of cough reflexes, lessened secretions, and decreased pain on postoperative coughing are advantages of this method.