596 CORRESPONDENCE Ann Thorac Surg 1993;56:593-7

service to the medical community and patient population as a whole.

John P . Clarke, M D

Virginia Beach Surgery, Ltd 1020 First Colonial Rd PO Box 4159 Virginia Beach, V A 23454

Reference 1. Ohri SK, Liakakos TA, Pathi V, Townsend ER, Fountain SW.

Primary repair of iatrogenic thoracic esophageal perforation and Boerhaave’s syndrome. Ann Thorac Surg 1993;55:603-6.

Reply To the Editor:

Although my colleagues and I understand Dr Clarke’s concern that many surgeons in the United States may have suitable qualifications to deal with these difficult cases, we were address- ing the problem that exists in the United Kingdom and undoubt- edly other countries, where because of the infrequency of the condition, it is often difficult to build up experience and indeed train younger surgeons in the management of this problem.

As a result, we have advocated the principle of sending such cases to “regional centers” such as ours, where this experience can be concentrated to the advantage of both patients and surgeons-in-training. In some ways, this is analogous to the approach adopted for trauma with the development of desig- nated trauma centers. The success of this policy is reflected in the number of cases that we presented in the article, which were treated over a relatively short period, and the subsequent out- come of these patients.

We believe The Annals of Thoracic Surgery to be an international journal, reflecting heterogenous opinions and surgical ap- proaches. The article’s scientific content is not in question, and we therefore do not wish to enter into a discussion that will be based on geographic biases.

Sunil K . Ohri, FRCS

Cardiothoracic Unit Hammersmith Hospital Royal Postgraduate Medical School Du Cane Rd London W12 OHS United Kingdom

Continuous Intercostal Bupivacaine To the Editor:

We wish to congratulate Deneuville and associates [l] on their recent article on continuous intercostal analgesia with 0.5% bupivacaine after thoracotomy. We have been convinced for some years of the efficacy of continuous extrapleural intercostal nerve block, which can provide profound analgesia and preser- vation of preoperative pulmonary function postoperatively [2]. The method of action of analgesia from this technique appears to be via the paravertebral route so that multiple unilateral intercos- tal nerve blocks are produced, the posterior primary ramus of the intercostal nerve is blocked (compared with multiple intercostal percutaneous nerve blocks), and the sympathetic chain is also blocked [3]. The efficacy of this technique compared with pla- cebo, intramuscular narcotics, and epidural morphine has been established [3, 41.

We have moved in two directions that have made an enormous improvement to our basic technique. We believe that preemptive analgesia is of the utmost importance in major surgical proce- dures and, therefore, all patients about to undergo thoracotomy receive a percutaneous paravertebral block followed by extra- pleural intercostal nerve block postoperatively with catheter insertion before closure of the chest as described by Sabanathan and associates [4]. The second development, which has been very important, is the use of balanced analgesia starting preop- eratively and consisting of opiate premedication combined with nonsteroidal antiinflammatory premedication [2].

In the light of this experience we would like to offer some explanations for some of the inconclusive findings in the study by Deneuville and associates [l]. Positioning the catheter from the second to the fifth rib appears to be unusually high, as most posterolateral thoracotomies are performed at the T5-6 interspace (although the level of thoracotomy in this study was not men- tioned). After the initial bolus the infusion rate of 3 mUh may be insufficient to allow distribution over an adequate number of dermatomes to ensure analgesia, particularly of the chest drain sites. We recommend 0.1 mL * kg-’ . h-’, ie, approximately double this volume (of 0.5% plain bupivacaine).

Employing the modifications mentioned above, continuous intercostal analgesia, we are convinced, will become the gold standard against which all other methods of pain relief for thoracotomy will be judged.

Jonathan Richardson, FCAnaes Sabaratnam Sabanathan, FRCS

Thoracic Department Bradford Royal lnfirma y Duckworth Lane Bradford, West Yorkshire BD9 6RJ United Kingdom

References 1.

2.

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4.

5.

Deneuville M, Bisserier A, Regnard JF, Chevalier M, Levas- seur P, Herve P. Continuous intercostal analgesia with 0.5% bupivacaine after thoracotomy: a randomized study. Ann Thorac Surg 1993;55:381-5. Richardson J, Sabanathan S, Mearns AJ, Evans C, Bembridge J, Dunne J. The effect of balanced analgesic premedication on postoperative analgesic requirements, pain scores and respi- ratory function following thoracotomy. J Pain SOC 1992;10:27. Eng J, Sabanathan S. Site of action of continuous extrapleural intercostal nerve block. Ann Thorac Surg 1991;51:387-9. Sabanathan S, Mearns AJ, Bickford Smith PJ, et al. Efficacy of continuous extrapleural intercostal nerve blocks on post- thoracotomy pain and pulmonary mechanics. Br J Surg 1990; 77221-5. Richardson J, Sabanathan S, Eng J, et al. Continuous intercos- tal nerve block versus epidural morphine for postthoracotomy analgesia. Ann Thorac Surg 1993;55:377430.

Neonatal Pneumonectomy To the Editor:

I wanted to clarify the status of the patient referred to in an article by Canver and associates [l]. This patient had a right pneumo- nectomy at 3 weeks of age for necrotizing bronchopneumonia secondary to agenesis of the right pulmonary artery. Doctor Szarnicki, in a subsequent letter to the editor [2], expressed concern about the possibility of right pneumonectomy syn- drome. Doctor Canver’s response indicated the patient was symptom free. At the time of his response, Dr Canver had left the State University of New York and, I am sure, was unaware of