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Intercostal Neuroma PAIN After Endoscopic Cholecystectomy: Diagnosis and Treatment
A. Lee Dellon, MD, PhD
Johns Hopkins University, Baltimore, MD, USA
Purpose: Chest wall or abdominal pain after endoscopic cholecystectomy is perceived to represent residual gastrointestinal problems. A subgroup of these patients, will have pain characterized by tenderness at the endoscopic portal site(s), with radiation from the costal margin towards the spine, representing injury to one or more intercostal nerves. It is the purpose to describe this patient population for the first time, outlining a diagnostic and therapeutic algorithm.
Method: Inclusion criteria: 1) right chest wall or abdominal pain persisting more than one year after endoscopic cholecystectomy, 2) relief of that pain with intercostal nerve block, 3) resection of intercostal nerves identified by nerve block, 4) at least a 6 month post-operative follow-up by telephone. Review from 2009 through 2011 identified one man and seven women meeting this criteria. Mean age was 44 years (range 18 to 74). Mean interval between cholecystectomy and intercostal neurectomy was 44.3 months (range 13 to 72 months). The proximal nerve end was implanted into latissimus dorsi or serratus muscle.
Results: Three patients had pain that included umbilicus and right lower quadrant, where groin/umbilical portals were placed. Two of these three patients required resection of the ilioinguinal/iliohypogastric nerves in addition to intercostal nerves; the third required resection of T10 within the rectus abdominus muscle through the umbilical portal.
Number of intercostal nerves resected was 2 in 2 patients, 3 in 4 patients, 4 in one patient, and 5 in one patient. The most common intercostal nerve combination resected was T6, T7, and T8.
At a mean of 18.3 months after the surgery, pre-op mean VAS of 8.9 (range 7 to 10) decreased to a mean of 3.6 (range 0 to 6), p < .01. One patient, with a post-op VAS of 6 required a second surgery to remove two additional intercostal nerves, after which his VAS became a 1, and is considered in the overall grading as an excellent result. Overall results were 5 excellent (63%), 2 good (25%), and one failure (12%).
Conclusions: Chest wall /right sided abdominal pain following endoscopic cholecystectomy may represent injury to intercostal and subcostal nerves by the endoscope. Diagnostic nerve blocks are essential to confirm the diagnosis and prepare the patient for post-operative region of numbness. Resection of appropriate intercostal nerves (usually three), and implantation of the proximal end into muscle, can be expected to give good to excellent results in 88% of patients.
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