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Introduction

Coronary artery bypass graft surgery (CABG) is a commonly preferred surgical intervention in the treatment of heart diseases. After CABG, patients may experience various complaints, such as pain and numbness, especially in the anterior chest wall. Such complaints may occur immediately after surgery or in the longer term. Although pain and numbness in the anterior chest wall after CABG are often temporary, the condition may become chronic for some patients. If left untreated, this postoperative pain reduces the quality of life and the patient’s satisfaction with cardiac surgery.^1–7

Pain and numbness in the anterior chest wall after CABG can be caused by several main reasons. The main reasons are sternotomy and stretching of the chest wall. Pain due to intercostal nerve damage in the thoracic wall where Internal Thoracic Artery (ITA) is harvested during CABG is also one of the essential causes of postoperative pain. Studies report that intercostal nerve damage occurs postoperatively in 75% of patients who had ITA harvested during CABG surgery. Along with pain, numbness can also be observed on the anterior chest wall, especially on the thorax where the ITA was removed.⁷

ITA is the standard and most preferred graft used for CABG because it can remain open for a long time.⁸ After harvesting of the ITA, hemostasis of the remaining inner thorax wall is usually done with the help of electrocautery. However, no standard heat setting is defined for this electrocautery heat power. Generally, the electrocautery power used for hemostasis can be at least 40 watts, 70–80 degree Celsius. Postoperative complaints such as pain and numbness on the left side of the sternum that lasts for months as a result of sensory nerve damage due to thermal burn in this area as a result of this high degree.⁹

According to general trends, cauterization is performed with 40 watts and above cautery heat power for hemostasis on the remaining thoracic inner wall after ITA harvesting. After ITA, harvesting, electrocautery power used for hemostasis on the remaining ITA bed on the inner surface of the thorax may damage surrounding tissues due to excessive heat. High watts and temperatures may cause tissue burns or unwanted damage. The probability of developing intercostal nerve damage increases proportionately to the high heat value—in this case, postoperative pain and patient dissatisfaction increase. The length of intensive care unit stay may be extended due to respiratory distress due to pain. As a result, treatment costs may increase due to higher postoperative pain levels, increased analgesic requirements, and increased intensive care duration.

This study investigated the effects of two different cautery powers, 20 and 40 watts, applied to hemostasis in the remaining inner thoracic wall after ITA harvesting on postoperative pain in the anterior chest wall.

Materials and Methods

This is a single-center, retrospective observational study. The study was approved by the Kastamonu University Ethics Committee (2024 -KAEK-125), and written informed consent was obtained from all participants before their inclusion in the study. It was obtained by scanning the retrospective files of the patients and the data in the hospital information management system. The patients’ demographic data (age, gender, additional diseases, etc) were scanned retrospectively from the hospital records. The two study groups consisted of equal numbers of patients. The same surgical team performed all surgeries.

This study examined 100 patients who underwent ITA harvesting for CABG between January 2022 and January 2025 in Cardiovascular Surgery clinic. Among the patients who underwent CABG surgery between these dates, patients with adequate vision and consciousness and who could comply with pain tests were included in the study. These patients were divided into two groups. Group 1 (n: 50 patients who coagulated with 20 watt to control bleeding in the remaining inner thoracic wall after ITA was removed) and Group 2 (n: 50 who coagulated with 40 watts to control bleeding in the remaining inner thoracic wall after ITA removed). The degree to which the ITA bed was cauterized with electrocautery during surgery was recorded during surgery for both patient groups.

After the surgery, the patients were observed in the cardiovascular surgery intensive care unit. As in routine, patients were followed up in terms of drainage. BPS was performed on the patients before extubation. After extubation, VAS tests were performed on the patients in the first 6 hours, 24 hours, and 7 days. In addition, all patients’ total days of intensive care and total hospital stay were recorded. It was investigated whether there was a difference between the two groups in terms of postoperative drainage amount and postoperative left sternum pain. The drainage amounts within the first 24 hours after surgery were calculated retrospectively from the cardiovascular surgery intensive care unit follow-up charts. After surgery, BPS was applied to the patients before extubation in the intensive care unit. After extubation, VAS tests were applied to the patients at the first 6 hours, 24 hours, and 7 days. It was evaluated with Behavioral Pain Scale (BPS) and Visual Analogue Scale (VAS) (a worldwide standard test for pain management and clinical assessment).¹⁰ Intensive care durations and total hospital stay days were recorded and compared for two groups.

Statistical Analysis

For statistical analysis, the SPSS version 25 program was applied. Mean and standard deviation values are used to present descriptive analyses. While normally distributed (parametric) variables were evaluated among the groups, the Student’s t-test was used. The Mann–Whitney U-test was used to assess non-parametric variables. A p-value <0.05 was evaluated as a statistically significant result. A formal a priori power analysis was not performed prior to the study. However, based on similar studies in the literature and considering feasibility within the study period, a sample size of 100 patients was deemed sufficient to detect clinically meaningful differences.⁷

Results

Group 1 and Group 2 were compared statistically regarding demographic data, comorbid conditions, and the number of coronary arteries bypassed. After these comparisons, no statistically significant difference was found in demographic data, comorbid conditions, or the number of coronary arteries bypassed. These preoperative clinical characteristics are shown in Table 1.

Table 1 Preoperative Clinical Characteristics

In the postoperative follow-up, ıntubation times were longer in Group 2 in terms of median value (7.5), which was considered statistically significant (p<0.001). No statistically significant difference was found between the two groups regarding drainage amounts (p=0.790). BPS>3, the patient’s pain was considered significant. Regarding BPS, the median value was found to be (1.7) in Group 1, and the median value was found to be (5.4) in Group 2. A statistically significant increase was found in Group 2 in BPS (p<0.001). VAS values taken 6, 24 hours after extubation, and 7 days after surgery were statistically significantly higher in Group 2 (p<0.001). Intensive care durations differed in both groups. Regarding days spent in intensive care, the median value was found to be (2.9) in Group 1, and the median value was found to be (3.4) in the 40-degree group. The 40-degree group was found to have a significantly longer intensive care stay (p=0.001). There was no significant difference between the groups regarding total hospital stay (p=0.439). Table 2 compares the two groups regarding postoperative intubated time, drainage, pain (BPS and VAS) and length of stay in the intensive care unit and hospital.

Table 2 Comparison Between the Two Groups Regarding Postoperative Drainage, Pain, and Length of Stay in the Intensive Care Unit and Hospital

BPS Score Mean between Groups 1 and 2 shown in Figure 1. The average BPS score measured in the 40 watt group (Group 2) was around 5.2, while this value was around 1.5 in the 20 watt group. This difference suggests that Group 2 caused higher behavioral pain symptoms. In addition, the lower BPS score in the 20 watt group indicates that this method is less uncomfortable in the postoperative period and provides more effective pain control.

Figure 1 Postoperative Behavioral Pain Scale (BPS) scores in Group 1 (20 W) and Group 2 (40 W). Note: Data are presented as mean ± standard deviation.

VAS Score Mean between Groups 1 and 2 shown in Figure 2. The average VAS score was approximately 4.5 in Group 2 at the 6th hour, while it was 1.5 in Group 1. Similarly, at the 24th hour, Group 2 had an average score of approximately 3.5, while Group 1 was below 1. On the 7th day, pain levels had decreased significantly in both groups, and the difference between the groups had decreased. However, the pain level in Group 2 was still higher than in Group 1.

Figure 2 Postoperative visual analog scale (VAS) scores at 6 hours, 24 hours, and 7 days in Group 1 (20 W) and Group 2 (40 W). Note: Data are presented as mean ± standard deviation.

Discussion

One of the most important causes of pain after CABG is sternotomy. Cutting the sternum during CABG can cause pain and tenderness for the patient during the healing process. In some patients, the pain process may be prolonged due to improper union of the cut bone or infection. Due to the intercostal nerves that are cut or stretched during sternotomy, there may be numbness and tingling in the anterior chest wall along with pain.⁷

In most patients, pain and numbness in the anterior chest wall after CABG improves within a few weeks. Although pain and numbness in the anterior chest wall after CABG usually improve on their own or with treatment, the condition can become chronic for some patients.^1,2,9,11,12 In some cases, persistent pain, especially in the early postoperative period, can also cause respiratory distress. In this case, an unwanted respiratory failure may develop.¹³

Although the most common cause of pain after CABG surgery is sternotomy and chest wall stretching, nerve damage in the inner thorax where the ITA for CABG is removed may also cause pain. In the study conducted by Mailis et al, the rate of anterior intercostal nerve injury after coronary artery bypass graft surgery using ITA was determined as 73%. In this study, definite nerve damage was detected in 73% of the subjects, and possible nerve damage was found in another 11% at the site of internal thoracic artery harvesting.⁷

Of course, ITA is the standard and most preferred graft for CABG due to its long-term patency. ITA is the most frequently preferred artery graft in CABG surgery due to its prolonged patency, suitability for coronary artery anastomosis, and non-requirement of proximal anastomosis. The ITA harvesting technique has always been debated for postoperative drainage. In addition to excellent long-term patency, pedicled ITA is preferred because it is easier and faster to prepare.⁹ In the clinic where the study was conducted, pedicled ITA procurement is preferred due to the ease of providing long-term patency. Especially after pedicled ITA harvesting, coagulating the remaining ITA bed on the thoracic wall with electrocautery and careful hemostasis is essential for less postoperative drainage.

The electrocautery powers used in surgery are known as follows. Low power (20–30 watts) generally targets a temperature range of 60–70°C, which is ideal for bleeding control. Medium power (40 watts) provides stronger coagulation by providing temperatures between 70°C and 80°C. However, more heat can cause damage to surrounding tissues. High power (60 watts and above) can create higher temperatures (80°C and above), which can cause tissue burns or unwanted damage.¹⁴

After ITA harvesting, hemostasis of the ITA bed remaining on the inner surface of the thorax is significant for postoperative drainage. Electrocautery is usually used for this bleeding control. However, there are differences in the heat power of the electrocautery used from clinic to clinic, and a standard heat degree is not specified. When the general approaches for the electrocautery power used for this purpose are considered as at least 40 watts, ie, 70–80 degrees, it can be said that complaints such as pain and numbness that last for months on the left side of the sternum in patients after surgery develop as a result of sensory nerve damage due to thermal burn in this region.

Since Albrecht Theodor Middeldorpf performed the first electrical surgical procedure using a galvanometer in 1854, electrocautery has been developed and plays a vital role in surgery. Middeldorpf was among the first to integrate the galvanocauteri (electrical coagulation) method into surgery. The term galvanocauteri is derived from the combination of the words “Galvano-” (electrical current) and “-cauter” (cauterization). Since then, electrocautery has become essential for hemostasis in surgical operations.^15,16 Electrocautery, an integral part of modern surgery, is based on an alternating current that causes division/coagulation without damaging nearby tissues.¹⁷ The coagulation mode feature present in electrocautery significantly reduces blood loss by providing hemostasis.¹⁸ In addition to providing almost perfect hemostasis, the widespread use of electrocautery (or galvanometer) devices in surgeries offers many advantages. However, due to incorrect use or excessive heat application, thermal damage and related undesirable effects such as pain and loss of sensation may also occur. The high-frequency electrical current applied with electrocautery generates heat in the tissues, damaging the surrounding tissues while coagulating the vessels. This damage can affect the nerves and cause pain or loss of sensation.¹⁹ It is suggested in the literature that the pain caused by electrocautery can be explained by thermal damage to the cutaneous nerve endings, just like in full-thickness burns.¹⁴

Studies on reducing pain due to ITA harvesting have been found in the literature. In the research conducted by Boodhwani et al it was stated that skeleton IMA harvesting reduces postoperative pain and numbness. However, in this article, it was interpreted that harvesting IMA to skeleton may prolong the duration of surgery.²⁰ With the same logic, we prefer pedicled ITA harvesting due to its ease of harvest and long-term patency.

All cardiovascular surgeons know that after ITA harvesting, coagulation of the remaining ITA bed on the thoracic wall with electrocautery for hemostasis is essential for less postoperative drainage. However, while electrocautery procedures using high temperatures for hemostasis provide effective bleeding control, they can also cause severe postoperative pain due to thermal nerve damage in the inner surface of the thorax. No article has been found in the literature regarding what this electrocautery temperature should be. However, in general practice, 40 watts and above electrocauterization is preferred for hemostasis of the ITA bed remaining on the inner surface of the thorax after ITA harvesting. When the electrocautery power used for hemostasis of the ITA bed remaining on the inner surface of the thorax after ITA harvesting is considered as at least 40 watts, ie, 70–80 degrees, it can be said that complaints such as pain and numbness on the left side of the sternum that lasts for months in patients after surgery develop as a result of sensory nerve damage due to thermal burn in this region. This study was planned with this logic. This study was planned considering that patients who underwent hemorrhage control of the inner surface of the thorax with a low electrocautery value of 20 watts after ITA harvesting may have fewer postoperative pain complaints due to less thermal damage than those who used 40 watts. For this purpose, 100 patients who underwent ITA harvesting for CABG and bypass grafting between January 2022 and January 2025 in a cardiovascular surgery clinic were examined.

The patients were divided into two groups: Group 1 (n: 50 patients whose anterior thoracic wall was coagulated with 20 watts) and Group 2 (n: 50 patients whose anterior thoracic wall was coagulated with 40 watts).

According to the results of this study, there was no statistically significant difference between Group 1 and Group 2 in terms of demographic data and comorbid conditions. According to the results of BPS and VAS evaluations, a statistically significant difference was observed in patients who used 20 watts of cautery power (Group 1) compared to the patient group who used 40 watts (Group 2) regarding less postoperative pain in the anterior chest wall. It was statistically significant that postoperative pain was less in those who underwent thoracic internal hemostasis with 20 watts in Group 1. No statistically significant difference was found between these two groups regarding postoperative drainage amounts according to 2 different cautery degrees. Length of stay in the intensive care unit differed in both groups. Regarding length of stay in the intensive care unit, in Group 2 was found to have a statistically significantly longer length of stay in intensive care unit. There was no significant difference between the groups regarding total hospital stay.

Of course, individual pain perception can of course affect the results. Therefore, patients who were able to adapt to the pain tests performed after surgery and who had sufficient mental and visual capacity were included in the study.

There are studies in the literature indicating that skeletal ITA harvesting reduces postoperative pain and numbness.²⁰ However, in this study, as pedicled ITA harvesting was performed on all patients in accordance with the clinic’s routine surgical practice and preference, a direct comparison with the skeletonized ITA technique in terms of postoperative pain could not be conducted.

The retrospective nature of this study and the lack of long-term follow-up are limitations that may affect the generalizability of the findings; however, when the literature on the subject was reviewed, no study was found investigating a possible relationship between the degree of cauterization of the remaining ITA bed on the inner chest wall after ITA harvesting for hemostasis and postoperative pain.

As highlighted in studies, pain is a condition that contributes significantly to increased hospital costs.^21,22 As noted in this study, shorter length of stay in the intensive care unit is particularly important in reducing hospital costs.

The study is about early chest wall pain after CABG, and it is obvious that more comprehensive studies are needed in the future regarding chronic pain. Although the study demonstrates a significant reduction in pain at day 7, the long-term implications of this finding, including its impact on the risk of chronic postoperative pain, remain unclear. Future prospective and longitudinal studies are warranted to further investigate these outcomes.

Conclusion

This study is based on the logic that lower electrocautery power, such as 20 watts, for hemostasis of the remaining inner thoracic wall after ITA harvest may reduce tissue and nerve damage. Using 20 watts instead of 40 watts in the study did not increase postoperative drainage and was associated with less pain and sensory loss, and increased patient comfort. Reduced pain also facilitated better respiratory function, potentially shortened ICU stay, and reduced treatment costs. These findings support the use of lower cautery power as a safe and cost-effective alternative for CABG surgery. These findings suggest that a simple intraoperative adjustment in electrocautery power may contribute to postoperative recovery and may contribute to surgical practice.

There are not many articles similar to this study in the literature. In this sense, this study is original. These results may be further validated and strengthened by larger, multi-center studies in the future.

Data Sharing Statement

https://doi.org/10.5281/zenodo.14589729.

Ethics Committee Approval

Ethics committee approval was received from Kastamonu University Faculty of Medicine ethics committee (2024-KAEK-125). The study was conducted by the principles of the Declaration of Helsinki.

Funding

The author received no financial support for this article’s research.

Disclosure

The author declares no conflicts of interest concerning the authorship and publication of this article.

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Certain patients with low-risk differentiated thyroid cancer can avoid postoperative radioiodine ablation following thyroidectomy, according to findings from the phase 3 IoN non-inferiority trial (NCT01398085) published in The Lancet.¹

Results from the study showed that outcomes in patients with pT1 or pT2 tumors and N0 or Nx nodal status who did not receive ablation were non-inferior to outcomes in patients receiving ablation. At a median follow-up of about 6.7 years (IQR, 4.8-8.6) across the overall intention-to-treat (ITT) population, there were 8 recurrences in the no ablation group compared with 9 in the ablation group. The 5-year recurrence-free survival (RFS) rate was 97.9% (95% CI, 96.1-99.7) vs 96.3% (95% CI, 93.9-98.7), respectively. The hazard ratio or risk difference was 0.5 (95% CI, –2.2 to 3.2;), meeting the study’s target non-inferiority margin of 5 percentage points, and the P value for non-inferiority of .033 was statistically significant.

Patients with pT3/pT3a tumors experienced recurrence more frequently (9%) compared with patients with pT1/pT2 tumors (3%), and patients with N1a nodal status (13%) had recurrence more often than patients with N0 or Nx status (2%).

Regarding safety, adverse events occurred at comparable rates between groups. The most frequently reported were fatigue (25% in no ablation arm vs 28% in ablation arm), lethargy (14% in both), and dry mouth (10% vs 9%). No treatment-related deaths were reported.

Study Background and Design

Providing the rationale for their study, Ujjal Mallick, MBBS MS FRCR, department of Oncology, Freeman Hospital, Newcastle, UK, and coauthors wrote, “Patients with differentiated thyroid cancer can often be treated with postoperative radioiodine (radioiodine ablation) after total thyroidectomy. The IoN trial was designed to assess whether RFS was non-inferior after no ablation compared with ablation in patients with low-risk differentiated thyroid cancer.”

The multi-center phase 3 IoN non-inferiority trial enrolled patients who had undergone complete (R0) resection via total thyroidectomy and had stage pT1, pT2, or pT3 disease, with nodal status of N0, Nx, or N1a. Patients were randomized in a 1:1 ratio to receive either 1.1 GBq of radioiodine ablation or no ablation following surgery.

Patient Characteristics

The ITT population included 504 patients enrolled at 33 cancer centers in the UK between June 26, 2012, and March 18, 2020. Overall, 251 were randomized to not receive ablation and 253 patients were randomized to receive ablation.

Baseline characteristics were well balanced between the 2 treatment arms. The median age was about 48 years and about 78% of patients were female. The median time from surgery to randomization was about 2.2 months.

Histologically, papillary carcinoma was the most common subtype in both groups (76% vs 81% in the no ablation vs ablation groups, respectively), followed by follicular (21% vs 15%) and oncocytic carcinoma (3% vs 4%). Multifocal tumors were present in 35% of patients without ablation and 38% with ablation. Staging was nearly identical across groups: pT1 (47%), pT2 (44%), and pT3/pT3a (9%). Nodal status was also similar: 68% were N0, 23% Nx, and 9% N1a in both groups.

Regarding surgical approach, most patients underwent two-stage thyroidectomy (59% vs 56%), followed by one-stage (40% vs 42%), with a few unknown cases. Central compartment neck dissection was performed in 16% of the no-ablation group and 20% of the ablation group.

Key Takeaway

“Long-term follow-up of the IoN trial shows that ablation is unnecessary in patients with differentiated thyroid cancer, specifically those with pT1 or T2 tumors that are N0 or Nx, as patients who did not receive ablation did not have inferior 5-year recurrence-free rates compared with those who did have ablation,” Mallick et al wrote in their concluding remarks.

REFERENCE:

Mallick U, Newbold K, Beasley M, et al. Thyroidectomy with or without postoperative radioiodine for patients with low-risk differentiated thyroid cancer in the UK (IoN): a randomised, multicentre, non-inferiority trial. Lancet. 2025;406(10498):52-62. doi: 10.1016/S0140-6736(25)00629-4.

Overview

The Global technical strategy for malaria 2016–2030, released in 2015, reaffirms the vision of a malaria-free world. For the first time, prevention of re-establishment was defined as a global malaria goal. This global guidance was developed to support malaria-free countries and those that are close to malaria elimination to prevent re-establishment. The document outlines key concepts and principles for preventing re-establishment and provides guidance on strategies, interventions, planning and management. Country examples are included to highlight good practices and illustrate practical applications. The guidance is intended for programme managers, coordinators, public health policymakers and health staff at national and subnational levels. While applicable to all malaria-free countries, it primarily targets those in tropical and subtropical regions where the risk of re-establishment remains significant.