A Potential Link Between Preoperative Inflammation Biomarkers and Acute Postoperative Pain Following VATS.

Acetaminophen plus a nonsteroidal anti-inflammatory drug decreases acute postoperative pain more than either drug alone

Little is known about physician attitudes, goals, or satisfaction regarding acute postoperative and cancer pain management. To provide quantitative data regarding the status of acute postoperative and cancer pain management by Michigan physicians. To measure physician confidence, preference, and satisfaction as well as identify their pain care goals for acute postoperative and cancer pain management. To evaluate variability in acute postoperative and cancer pain decision making based upon physician demographic characteristics, knowledge, and attitudes. A cross-sectional survey, which included two cancer and three acute postoperative pain vignettes. A randomly-selected sample of three hundred sixty-eight licensed Michigan physicians who provide clinical care for acute postoperative and cancer pain patients. The majority of respondents (>50%) reported providing acute postoperative pain care frequently, while a minority (<20%) reported doing so for cancer pain. The majority of the physicians (>75%) reported goals of at least adequate pain relief without distress for both acute postoperative and cancer pain. Physicians more frequently chose the optimal pain management response for men following prostatectomy (56.2%) than for women following myomectomy (42%). They also chose the optimal response for metastatic prostate cancer more frequently (16.3%) than for metastatic breast cancer pain management (10.7%). These data highlight physician variability in acute postoperative and cancer pain management decision making. Further study of the physician variable is necessary to improve the management of acute postoperative and cancer pain.

Brain activation due to postoperative pain from the right hand measured with regional cerebral blood flow using positron emission tomography

ABSTRACTObjectives: The aim of this research is by using sociological methods of scientific research for tracking the pain and satisfaction indicators to prove that decreasing the number of ports in the VATS (Video-assisted thoracic surgery) for Malignant Pleural Effusion reduces postoperative pain and improves patient’s satisfaction.Methods: Our study included 117 VATS procedures performed in the period from 01 January 2013 to 31 September 2016. The sociological method used to measure the pain indicator was an interview. The severity of postoperative pain was determined and reported according to a ten-point pain visual analogue scale (VAS). The degree of satisfaction was determined and reported according to a six-point and ten-point grading systems on the basis of a research interview procedure.Results: In the single-port method, the verbal pain scale for all the days covered by the research study statistically showed significantly lower values (P ˂ 0.0001) in comparison with the conventional method (P ˂ 0.0001). With regard to the patient’s satisfaction, determined on the basis of the six-point system, the results were as follows: conventional VATS approach – average 3.1 with a standard deviation of 1.1 and ranging from 0 to 5; single-port VATS approach – average 4.3 with a standard deviation of 1.0 and within the range from 0 to 6. Conventional VATS approach – 6.8 – neutral. Single-port VATS approach – 8.1 – prevailing satisfaction.Conclusions: Based on our study and the studies of other authors, it can be concluded that postoperative pain and satisfaction after VATS in patients with MPE (Malignant pleural effusion) are influenced by the number of ports and the one-port technique shows better results than the conventional three-port method.The research study was registered and approved by the Clinical Research and Ethics Committee at the ‘Prof. Dr. Stoyan Kirkovich’ AD University Multi-Profile Hospital for Active Treatment Hospital, Stara Zagora. According to Protocol No. 11, Ref. No. 12471/30.10.2015 approved are the methods used by the sociological research study which uses predefined indicators to track patients who have undergone conventional VATS and single-port VATS. Indicators: postoperative pain and satisfaction.

Recent advances in postoperative pain therapy

ONE potential adverse outcome from surgery is chronic pain. Analysis of predictive and pathologic factors is important to develop rational strategies to prevent this problem. Additionally, the natural history of patients with and without persistent pain after surgery provides an opportunity to improve the understanding of the physiology and psychology of chronic pain. Ideally, studies of chronic postoperative pain should include (1) sufficient preoperative data (assessment of pain, physiologic and psychologic risk factors for chronic pain); (2) detailed descriptions of the operative approaches used (location and length of incisions, handling of nerves and muscles); (3) the intensity and character of acute postoperative pain and its management; and (4) follow-up at intervals to 1 yr or more. In addition, there would be information about postoperative interventions that may influence pain, such as radiation therapy or chemotherapy. At long-term follow-up visits, patient function, physical signs, and symptoms would be evaluated using a standardized algorithm, including quantitative and descriptive pain assessments. We found no studies that contain all of these data. For this review, we specifically sought population data that reflect the incidence of chronic postoperative pain or predictors (medical, physiologic, and psychologic) of chronic pain. We selected five groups of surgeries (limb amputations, breast surgery, gallbladder surgery, lung surgery, and inguinal hernia surgery). These surgeries were selected because the incidence of pain is known to be high, thus improving the probability of detecting predictive factors. They also represent a range of major surgical procedures.

Controlled-release opioids cause harm and should be avoided in management of postoperative pain in opioid naïve patients

Intraoperative low-dose ketamine infusion has been reported to be an effective adjuvant to opioids for postoperative pain control without major side effects, but it has not been tested in video-assisted thoracic surgery (VATS). The aim of this study was to examine the effect of low-dose intraoperative intravenous ketamine infusion on 24-hour morphine requirement and acute postoperative pain following VATS for lung resection. This study was a single center, randomized, double-blind, placebo-controlled study. Thirty-two patients undergoing elective VATS for lung resection in a university hospital were included. Patients were randomly allocated (1:1 ratio) to receive either intraoperative low-dose ketamine (0.2 mg/kg/h) or normal saline infusion starting from intubation to the beginning of chest closure. All patients received multilevel thoracic paravertebral block (TPVB) and morphine was administered postoperatively via the patient-controlled analgesia pump using the same protocol. Time to first analgesia, postoperative cumulative morphine doses at 10, 30 minutes, and the consecutive 1, 2, 6, 12, 18, and 24 hours were recorded. Pain intensity during rest and deep breathing were also assessed by numeric rating scale (NRS) score at 1- and 24-hour postoperatively. There was no significant difference in median (P25, P75) cumulative 24-hour morphine requirement between the ketamine and the control groups [15 (5.5, 29.5) vs. 22.5 (15.3, 40.8) mg, P=0.090]. Patients in ketamine group had significantly longer median pain free time than the control group (27 vs. 2 minutes, P=0.006). No difference in overall NRS score at rest or during deep breathing at 1- and 24-hour postoperatively was demonstrated (P=0.861). Intraoperative low dose ketamine infusion in addition to TPVB does not reduce postoperative morphine consumption or pain intensity but may prolong pain free time in patients undergoing VATS for lung resection.

This prospective study was designed to examine the associations of demographic, clinical, psychological and neuroendocrine factors with acute and chronic post-operative pain following partial mastectomy. Sixty-four female patients scheduled for partial mastectomy were enrolled. Pre-operative anxiety/depression was assessed, using the Hospital Anxiety and Depression Scale (HADS). Pre-operative 24-h urinary cortisol levels were measured 2days before surgery. Post-operative pain was examined using a visual analog scale (VAS) for acute pain on 0-2 post-operative day (POD), and a short-form McGill Pain Questionnaire for chronic pain at 6months after surgery. In the last 29 subjects, post-operative 24-h urinary cortisol levels were also measured on 0 POD and were subjected to correlation analysis. Multivariate logistic regression analysis revealed that lower pre-operative cortisol secretion and greater pre-operative anxiety were significantly associated with an increased risk of moderate to severe acute post-operative pain [Odds Ratio (95% Confidence Interval); 0.96 (0.92-0.98), and 1.24 (1.04-1.54)], and that patients with greater pre-operative anxiety and moderate to severe acute pain were more likely to develop chronic post-operative pain [OR (95% CI); 1.63 (1.23-2.40), and 5.07 (1.30-24.6)]. Correlational analysis demonstrated that the post-operative cortisol level was inversely correlated with pre-operative anxiety and the intensity of acute post-operative pain (r=-0.40, p<0.05, and r=-0.50, p<0.01), but not with the intensity of chronic pain. This study confirms that pre-operative anxiety is associated with both acute and chronic post-operative pain after partial mastectomy. It also suggests that lower perioperative cortisol secretion might be associated with greater acute post-operative pain. Although the associations between psychological stress/stress hormone levels and chronic post-operative pain remain to be determined, pre-operative psychological stress and perioperative cortisol levels are correlated with acute post-operative pain.

Many of the thoracic operations that previously required a thoracotomy incision can now be performed with several small incisions and video-assisted thoracic surgery (VATS). Although there have been reports of less pain and less impairment of pulmonary function with VATS compared with thoracotomy, 1 many VATS patients report significant acute and chronic postoperative pain. Treating thoracoscopic pain effectively and minimizing the later development of chronic pain requires familiarity with a wide spectrum of analgesic techniques. An important variable in the analgesic plan for VATS is the likelihood of converting to an open thoracotomy. Conversion may be due to technical difficulties, inadequate lung separation, or bleeding, and may be more likely when the surgeon has less experience with VATS. The likelihood of conversion to an open procedure must be assessed preoperatively. If a VATS procedure is converted to a thoracotomy and analgesia (such as an epidural) is not in place, the patient’s recovery may be impaired. If not wellcontrolled, postoperative thoracic pain can lead to splinting and may impair the patient’s ability to take deep breaths following thoracic surgery. It is difficult to state precisely the incidence of pain following thoracoscopy, as the extent and severity varies according to surgical technique, patient sensitivity, and anesthetic pain management. In a recent survey of Dutch thoracic surgery patients, 47% of the VATS patients reported chronic pain. 2 In an earlier study, the incidence of chronic pain was reported to be 36% in VATS patients undergoing wedge resection. 3 It might seem intuitive that performing the surgery by thoracoscopy, which utilizes small incisions, would lead to less postoperative pain. However, the introduction of trocars during thoracoscopy may injure intercostal nerves, and additional manipulation of these instruments during the surgery may traumatize these nerves further by compression against ribs. 4 If a lobectomy is being performed, an incision will need to be enlarged in order to extract the specimen, and a rib retractor may be required. Also, the duration of the surgery may be greater using VATS. Ipsilateral shoulder pain is a common complaint following VATS, and in one study, it was reported to be chronic in 10% of patients. 5

The widely accepted and still increasing use of video-assisted thoracic surgery (VATS) in pleuro-pulmonary pathology imposes the need to deal with two major pitfalls: the first is to avoid its unselective use, while the second relates to inappropriate rejection of VATS on the basis of “insufficient radicality”. Unlike a quite established role of VATS in lung cancer patients, in patients with pleural empyema, the role of VATS is less clearly defined. The current evidence about VATS in patients with pleural empyema could be summarised as follows: VATS is accepted as a useful treatment option for fibrinopurulent empyema, but the treatment failure rate increases with the increasing proportion of stage III empyema, necessitating further surgical options like thoracotomy and decortication. As both pulmonologists and surgeons deal with diagnosis and treatment of pleural empyema, this article is an attempt to highlight the existing evidence in a more user-friendly way in order to help practising physicians to optimise the use of VATS in these patients. In other words, in the absence of randomised studies comparing VATS and thoracotomy, the key question to be answered is: are there any pre-operative findings that can be used to select patients for initial VATS versus proceeding directly to a thoracotomy?

Chronic postsurgical pain (CPSP) after video-assisted thoracic surgery (VATS) has been a focus for research and clinical improvement for decades. However, large-scale epidemiological reports from prospective studies are still lacking. The goal of this study was to present the CPSP profiles after VATS from a nationwide survey. Patients who were scheduled for VATS at the participating centres were prospectively enrolled in this multicentre observational study between August 1st and September 30th, 2022. Comprehensive assessments of demographic, pain, clinical, and psychological factors were performed before surgery. During surgery, surgical factors, drainage tubes and anaesthesiologic factors were recorded. Postoperative pain was assessed via NRS (Numeric Rating Scale), BPI-9 (Brief Pain Inventory 9 questions) and DN-4 (Douleur Neuropathique 4 questions, as Neuropathic pain four questions in English) interviews on postoperative days 1-3, at discharge, and 3 and 6 months after surgery. Phone interviews were performed at 3- and 6-month follow-ups. A total of 904 patients were recruited, 882 of whom completed the 6-month follow-up and were analysed for CPSP. The incidence rates of CPSP 3 and 6 months after VATS were 38.3% [95% confidence interval (CI): 35.2-41.6%] and 26.8% (95% CI: 23.9-29.8%), respectively, with 10.7% and 4.7% of the cohort (94 and 41 of the 882 patients, respectively) reporting moderate to severe pain (NRS ≥3), respectively. In contrast to previous results for thoracotomy, only 0.5% of the patients complained of neuropathic pain in this study. Acute postoperative pain was significantly related to the incidence of CPSP. CPSP is still a common problem after thoracic surgery (6-month incidence of 26.8%). However, the characteristics of pain may have changed as the surgery becomes less invasive.

Acute post-operative pain following thoracic surgery procedures is still an unresolved problem despite the introduction of minimally invasive procedures such as video assisted surgery. Until now it is never investigated if different surgical instruments could influence post-operative pain. The aim of our study is to investigate the role of different type of trocar on post-operative pain in minimally invasive thoracic surgery. This was a prospective randomized single center study. We identified 53 patients randomized into three groups underwent single port thoracoscopy for malignant pleural effusion with drainage of the fluid and talc poudrage. The three groups differ for the trocar type, rigid, flexible and wound protector. We compared the postoperative pain between the three groups in which there was no statistical difference. Rigid trocar seems to give a more stable level of pain during the days, flexible trocar gains more pain in the first few hours, however the pain at discharge decreases significantly, reaching the similar values, in all the three groups. The association between pain at discharge and operative time or days of drainage was analyzed by means of linear regression, no statistically significant difference was found. Our study showed that different type of trocars during video assisted thoracic surgery (VATS) produces similar level of acute postoperative pain. In future, further randomized study with a great number of patients enrolled needs to confirm our results.

Preoperative pain sensitivity and its correlation with postoperative acute and chronic pain: a systematic review and meta-analysis

Acute postsurgical pain, probably including acute neuropathic pain (ANeP), starts at the early postoperative period, and chronic postsurgical pain including chronic neuropathic pain (CNeP) persists at least 3 months after surgery. Although it must be important for prevention and treatment of acute and chronic postoperative pain to reveal the time course of postoperative neuropathic characteristics, a neuropathic pain profile after surgery has not been evaluated.Pain status at the surgical site in adult patients who underwent video-assisted thoracic surgery (VATS) for lung cancer was prospectively assessed until 12 months after surgery. Neuropathic characteristics were assessed using the Douleur Neuropathique 4 (DN4) questionnaire until 6 days after surgery and the DN2 questionnaire throughout the study.Twenty-seven patients were enrolled in this study. Pain intensity at surgical sites were significantly higher at 1 and 6 days after surgery during resting state, and were also significantly higher at 3, 6, and 12 months after surgery during movement than those before surgery. The incidence of ANeP was 33.3% at 1 day, and 18.5% at 6 days after surgery. The incidence of CNeP decreased to 12.5% at 3 months, 5.0% at 6 months, and 0.0% at 12 months after surgery. The number of neuropathic characteristics, assessed by DN2 scores, significantly increased at 1 and 6 days after surgery, compared to those before surgery. DN2 scores at 3, 6, and 12 months after surgery, however, showed no significant differences compared to those before surgery.In patients with acute postsurgical pain, 20% to 30% of patients show ANeP characteristics, and the incidence of CNeP gradually decreases after VATS in patients with chronic postsurgical pain.