Lower Incidence Of Postoperative Pain Research Articles

Laparoscopic cholecystectomy versus minilaparotomy in cholelithiasis: systematic review and meta-analysis

IntroductionA introdução da técnica laparoscópica em 1985 foi um fator importante na colecistectomia por representar técnica menos invasiva, resultado estético melhor e menor risco cirúrgico comparado ao procedimento laparotômico.AimTo compare laparoscopic and minilaparotomy cholecystectomy in the treatment of cholelithiasis.MethodsA systematic review of randomized clinical trials, which included studies from four databases (Medline, Embase, Cochrane and Lilacs) was performed. The keywords used were "Cholecystectomy", "Cholecystectomy, Laparoscopic" and "Laparotomy". The methodological quality of primary studies was assessed by the Grade system.ResultsTen randomized controlled trials were included, totaling 2043 patients, 1020 in Laparoscopy group and 1023 in Minilaparotomy group. Laparoscopic cholecystectomy dispensed shorter length of hospital stay (p<0.00001) and return to work activities (p<0.00001) compared to minilaparotomy, and the minilaparotomy shorter operative time (p<0.00001) compared to laparoscopy. Laparoscopy decrease the risk of postoperative pain (NNT=7) and infectious complications (NNT=50). There was no statistical difference between the two groups regarding conversion (p=0,06) and surgical reinterventions (p=0,27), gall bladder's perforation (p=0,98), incidence of common bile duct injury (p=1.00), surgical site infection (p=0,52) and paralytic ileus (p=0,22).ConclusionIn cholelithiasis, laparoscopic cholecystectomy is associated with a lower incidence of postoperative pain and infectious complications, as well as shorter length of hospital stay and time to return to work activities compared to minilaparotomy cholecystectomy.

Postoperative Analgesia in Children After Propofol Versus Sevoflurane Anesthesia

Postoperative analgesia remains a problem, especially in pediatric patients. We hypothesize that patients anesthetized with sevoflurane have more postoperative pain than with propofol. Randomized, prospective, double-blind study. University teaching hospital. The subjects were 88 premedicated children, aged 3-6 years, and American Society of Anesthesiologists (ASA) Physical Status I or II. Subjectsunderwent hernia repair surgery. Anesthesia was maintained with propofol (group P, N = 46) or sevoflurane (group S, N = 42) and fentanyl was administered during surgery. All children before surgical incision received 40 mg/kg paracetamol, rectally. Prior to wound closure, the margins were infiltrated with 0.5% bupivacaine. The primary outcome was pain score assessed by Faces Pain Scale (FPS) 2 hours postoperatively. The secondary outcomes included recovery time and adverse events within the first 2 hours. Group S had a significantly higher proportion of patients who exhibited postoperative pain than group P (24.3% vs 4.5%, respectively; P < 0.05). FPS score in group P was 1.2 ± 0.6, compared with 3.4 ± 1.5 in group S (P < 0.001). Mean recovery time in group S was significantly shorter than the corresponding mean for group P (10.1 ± 1.3 vs 16.5 ± 5.4 minutes, respectively; P < 0.001). In children, anesthesia maintenance with propofol was associated with a significantly lower incidence of postoperative pain than with sevoflurane.

Teaching and training in laparoscopic inguinal hernia repair (TAPP): impact of the learning curve on patient outcome

On the basis of lower incidence of postoperative pain and faster recovery compared with open techniques, the laparoscopic transabdominal preperitoneal patch plastic (TAPP) technique was established as a leading mode of inguinal hernia repair. In contrast to open hernia repairs, which are well integrated in the training of young surgeons, TAPP is still considered a more difficult surgical procedure, raising the questions of how to include this technique in trainee programs and how to provide appropriate training. Out of 15,101 TAPP procedures performed in our department between 1993 and 2007, we analyzed 254 operations that occurred from April 2004 to February 2007 by young trainees (between the second and fourth years of surgical training). The analysis compared the trainees' TAPP operations with 3,200 TAPP procedures performed by experienced surgeons in the same time period, and with the first 254 TAPP operations in our department performed by pioneers who introduced this technique in 1993. In the 254 operations performed by young trainees, the mean operation time was 59 min, the morbidity rate was 3.2 %, and the recurrence rate was 0.4 %. Compared to experienced surgeons, we found no significant difference in recurrence rate and morbidity. For operation time, however, the young trainees demonstrated a learning curve with continuous improvement until the end of the study period approaching expert level. Pioneers also demonstrated a clear learning curve in operation time and additionally also regarding morbidity and recurrence rate. Our study demonstrates that the TAPP learning curve of young trainees is only related to operation time. Therefore, TAPP is a safe and reproducible technique when performed by young trainees under the supervision of experienced laparoscopic surgeons. With an adequate program, the technique can be learned quickly, skillfully, and safely when a standardized technique is used. It should be included as a fundamental part of state-of-the-art trainee programs.

The role of hemorrhoidectomy in rectocele complicated by grade 3–4 hemorrhoids

We read with great interest the article by Leal et al. [1] in which the authors concluded that the transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS procedure) has satisfactory anatomic and functional results with a low incidence of postoperative pain and complications. A rectocele is an abnormal sac-like projection of the anterior rectum into the posterior vaginal wall. Women commonly complain of stool trapping, a form of obstructed defecation, and report requiring digital pressure through the vagina in order to pass stools. The diagnosis of rectocele can be easily made on rectal examination. Defecography can be used for diagnosis or surgical decision making [2]. Stool trapping requiring digital evacuation or vaginal support and large protruding rectoceles are the major criteria for operative intervention [3]. Rectocele can be treated with a variety of local surgical approaches including the technique used by authors for rectocele complicated by rectal mucosal prolapse. Rectocele can be complicated by other perianal pathologies like hemorrhoids. We would like to share our experience of patients with grade 3 and 4 hemorrhoids coexisting with symptomatic rectocele. Eight women presented with some complaint of stool trapping, constipation, anal swelling and bright red blood per rectum. Rectocele and grade 3–4 hemorrhoids were diagnosed based on the history, physical examination, colonoscopy and defecography. We planned a 3-quadrant hemorrhoidectomy with Liga-Sure as an initial treatment. After recovery, we saw that symptoms related to rectocele were improved in all of the patients, and defecography was normal. Postsurgical inflammation and fibrosis in 3-quadrant hemorrhoidectomy may increase the tightness in the anal mucosa and prevent bulging into the vagina. We think that a 3-quadrant hemorrhoidectomy rather than a circular mucosectomy causes more tightness in anal canal mucosa and better recovery for patients with coexisting rectocele.

Who Benefits from Oncoplastic Surgical Techniques?

Breast-conserving therapy, which includes wide local excision of the tumor followed by irradiation, has become a standard treatment option for women with early-stage invasive breast cancer. The potential advantages of conservative breast surgery include the minor outpatient nature of the procedures, lower incidence of post-operative pain and complications, preservation of the breast and nipple areolar complex, and shorter delay to adjuvant therapy. However, not all patients are optimal candidates for breast-conserving procedures. Oncoplastic techniques combine the removal of breast cancer tumors in combination with either local volume replacement techniques to correct small defects, or by immediate reconstruction of larger defects using techniques of plastic surgery with or without contralateral breast procedures for symmetry. Therefore, oncoplastic techniques offer the potential to perform a wider excision of the tumor with an improved cosmetic result, thus potentially increasing the eligible pool for breast conservation.

Optimizing conservative breast surgery

The potential advantages of conservative breast surgery include the minor outpatient nature of the procedures, lower incidence of postoperative pain and complications, preservation of the breast and nipple areolar complex, and shorter delay to adjuvant therapy. In order to optimize the number of patients eligible for conservative breast surgery, one must utilize a multidisciplinary team approach. Imaging implications, use of neoadjuvant therapy for downsizing tumors, oncoplastic techniques, adjuvant radiation options, and pathological assessment are discussed.

Postoperative pain after primary endodontic treatment and retreatment of asimptomatic teeth

Introduction. Postoperative pain may develop after chemomechanical preparation during endodontic treatment or retreatment. It is associated with acute apical periodontitis caused by bacteria penetrated from the root canal into the periapical tissue. The purpose of this study was to evaluate the incidence of postoperative pain during endodontic treatment after intracanal medication performed with calcium hydroxide (CH) paste or 1% chlorhexidine gel (CHX). Material and Methods. The study included 22 asymptomatic teeth in both male and female patients. Fourteen teeth had the diagnosis of pulp necrosis and the other eight were retreatment cases. The root canals were prepared by crown-down technique using K files and copious irrigation with 0.5% sodium hypochlorite (NaOCl). Intracanal dressing was performed using either calcium hydroxide paste or 1% CHX gel. Each medicament was placed in the root canals of eleven randomly selected teeth. The teeth were restored with temporary filling. Postoperative pain was registered during the seven day period between two appointments. The level of pain was rated as follows: no pain, mild pain, moderate pain and severe pain (flare-up). The obtained data was analyzed using Fisher exact test. The level of significance was ?=0.05. Results. Postoperative pain was absent in 77.3% of total number of treated teeth. Severe pain (flare-up) was registered in 2 cases (9%). There was no significant difference in pain incidence between the CH paste and CHX gel group (p=0.610). Conclusion. Endodontic procedure used in this study which considered root canal instrumentation and irrigation followed by intracanal medication with CH and CHX resulted in low incidence of postoperative pain.

Clinical and functional evaluation of patients with rectocele and mucosal prolapse treated with transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS)

BackgroundThe aim of the present study was to make a preoperative and postoperative clinical and functional evaluation of patients who underwent transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS procedure) as treatment for obstructed defecation syndrome (ODS) caused by rectocele and rectal mucosal prolapse (RMP).MethodsThis prospective study included 35 female patients, 34 multiparous and one nulliparous, with an average age of 47.5 years (range 31–67 years), rectocele grade II (n = 13/37.1%) or grade III (n = 22/62.9%), associated with RMP. The study parameters included ODS, constipation, functional continence scores and pre- and postoperative cinedefecographic findings.ResultsThe average preoperative ODS score, the constipation score and the functional continence score were significantly reduced after surgery from 10.63 to 2.91 (p = 0.001), 15.23 to 4.46 (p = 0.001) and 2.77 to 1.71 (p = 0.001), respectively. Between the first and the eighth postoperative day, the average visual analog scale pain score fell from 5.23 to 1.20 (p = 0.001). Satisfaction with treatment outcome was 79.97, 86.54, 87.65 and 88.06 at 1, 3, 6 and 12 months, respectively. Cinedefecography revealed average reductions in rectocele size from 19.23 ± 8.84 mm (3–42) to 6.68 ± 3.65 mm (range 0–7) at rest and from 34.89 ± 12.30 mm (range 20–70) to 10.94 ± 5.97 mm (range 0–25) during evacuation (both P = 0.001).ConclusionThe TRREMS procedure is a safe and efficient technique associated with satisfactory anatomic and functional results and with a low incidence of postoperative pain and complications.

The relationship of intracanal medicaments to postoperative pain

Objective To evaluate the incidence of postoperative pain after intracanal dressings with either a calcium hydroxide/camphorated paramonochlorophenol or 0.12% chlorhexidine solution. Methods 158 asymptomatic teeth had their canals dressed with either CH or CHX. The incidence of different intensity levels of postoperative pain was registered for the period between appointments. Results Data revealed that 84.2% of the total number of cases treated with either medicament showed absence of any level of pain. No case medicated with CH and five cases( 6.3% )medicated with CHX were categorized as flare-ups. There were no statistically significant differences between all possible comparisons involving the two medicaments in treatment/retreatment cases and teeth with/without apical periodontitis lesions. Conclusion The low incidence of postoperative pain after the use of both medications, coupled to their antimicrobial effectiveness, gives support to using one or the other in routine treatment/retreatment. Key words: Endodontic treatment; Calcium hydroxide; Chlorhexidine; Postoperative pain; flare-ups

Postoperative Pain in Multiple-visit and Single-visit Root Canal Treatment

Introduction The purpose of the present study was to evaluate postoperative pain after root canal treatment at the Department of Conservative Dentistry, Faculty of Dentistry, University of Khartoum, Sudan. Methods Two hundred thirty-four patients were included in this study; age range was 18–62 years. Conventional endodontic treatment was carried out in the included teeth by the undergraduate dental students in a single visit or multiple visits. The chemomechanical preparation of root canals was done by a modified double-flared technique with combination of hand instruments. Postoperative pain was recorded by each patient by using visual analogue scale in well-defined categories at 2 time intervals, 12 hours and 24 hours. Results Data were analyzed with the χ 2 test. The overall incidence of postoperative pain was 9.0% after 12 hours and 24 hours. Postoperative pain developed in 15.9% of the patients with history of preoperative pain, whereas 7.1% had postoperative pain among those without history of preoperative pain. There was no significant difference in postoperative pain between single-visit and multiple-visit root canal treatment (RCT). Conclusions Within the limitations of the present study there was a low incidence of postoperative pain after conventional RCT. No significant difference exists in postoperative pain after single-visit or multiple-visit RCT.

Sutureless mesh fibrin glue incisional hernia repair

The aim of this study is to evaluate the usefulness of sutureless incisional open hernia repair with mesh fixation only using a fibrin glue sealant. From 2002 to 2007, 40 patients underwent surgical recurrent incisional hernia repair, consisting of a sutureless positioning of a retromuscolar-preperitoneal polypropylene stiff mesh, fixed only with 2 ml of human fibrin glue. The average hospitalization period was 3 days; postoperative complications occurred in seven patients: wound infection in four patients and hematoma in three patients. Seroma was not observed. Postoperative pain occurred in two patients, while chronic pain occurred in one patient; the remaining 37 patients were pain-free. The use of an open retromuscolar mesh is an easy, inexpensive and relatively safe method to repair large incisional hernias. In our study the use of fibrin glue sealant demonstrated a low incidence of postoperative pain and short hospitalization.

Postoperative pain following the use of two different intracanal medications

This study evaluated the incidence of postoperative pain after intracanal dressings with either 0.12% chlorhexidine digluconate gel (CHX) or a calcium hydroxide/camphorated paramonochlorophenol/glycerin paste (CH/CPMC). Overall, 138 asymptomatic teeth had their canals instrumented under irrigation with 2.5% NaOCl and then dressed with either CH/CPMC or CHX. The incidence of different intensity levels of postoperative pain was registered for the period between appointments. Data revealed that 84% of the total number of cases treated with either medicament showed absence of any level of pain. No case medicated with CH/CPMC and four cases (5.8%) medicated with CHX were categorized as flare-ups. There were no statistically significant differences between all possible comparisons involving the two medicaments in treatment/retreatment cases and teeth with/without apical periodontitis lesions. The low incidence of postoperative pain after the use of both medications, coupled to their antimicrobial effectiveness, gives support to using one or the other in routine treatment/retreatment.

The efficacy of pre-emptive tramadol in orthopaedic day-surgery

It has been suggested that there may be some advantage in pre-emptive administration of analgesics, which may be of some relevance in day-surgery. Post-operative pain control is often difficult due to the reluctance to use potent analgesics, whose side effects include nausea and vomiting, which are an important cause of delayed discharge. In order to test the potential beneficial effects of pre-emptive analgesia, 110 day-surgery patients were randomly allocated to receive either pre-emptive tramadol or a placebo pre-operatively. Per and postoperative complications were recorded following administration of a standard anaesthetic, comprising intravenous induction with propofol and maintenance with isoflurane. Post operative analgesia and anti-emetics were administered as required. Patients who received tramadol had a slightly lower incidence of postoperative pain, but at the expense of increased nausea; all differences were not significant.

Anaesthesia for surgical decompression of the orbit in severe thyroid orbitiopathy

Anaesthesia for surgical decompression of the orbit in severe thyroid orbitiopathy has rarely been reported in the literature. This review highlights patients’, anaesthetic and surgical factors of relevance. We carried out a retrospective analysis over a 3-year period of the records of 35 patients who had undergone surgical orbital decompression via a trans-lid approach under general anaesthesia. A total of 58 decompressions were performed on 35 subjects (26 women, 9 men; age range 34–76 years). Twenty-four patients had bilateral decompressions (seven had both sides performed simultaneously, whereas 17 had each side performed separately at least one month apart). Eleven required unilateral decompression only. Surgery was repeated on six occasions in four of the 35 patients. The main indications for surgery were compressive optic neuropathy (n = 17) and disfiguring proptosis (n = 19). Fourteen patients had more than one indication. Of the 35 patients, 33 had a history of hyperthyroidism whereas the remaining two were clinically and biochemically euthyroid. In all cases, T4/TSH levels were normal pre-operatively. Two thirds were smokers (the majority smoking 10–20 cigarettes/day). Pre-operative morbidities were as follows: diabetes mellitus (n = 5), chronic airflow limitation (n = 4), asthma (n = 4), hypertension (n = 4), obesity (n = 3), ischaemic heart disease (n = 2), arrhythmias (n = 2) and CVA (n = 1). Five had 2–3 comorbidities. Fifty-one percent were taking prednisolone pre-operatively (dose range 10–80 mg). Average duration of anaesthesia was 119 min for unilateral surgery and 184 min for bilateral surgery. In 88% of cases, balanced anaesthesia involved a volatile agent (isoflurane > sevoflurane > enflurane), O2 /N2 O mixture and either remifentanil or fentanyl ± morphine, whereas in the remaining 12% of cases remifentanil, target-controlled infusion of propofol and O2/air mixtures were used. Normotensive anaesthesia was used throughout. Intravenous acetazolamide was given on induction to reduce intraocular pressure. Subcutaneous local anaesthetic (bupivacaine with epinephrine) was infiltrated under the eyelid before starting surgery. Ketorolac and pethidine were given as adjuncts in 29% and < 1% of cases respectively. In 26% of cases, anticholinergic therapy was required for bradycardia resulting from orbital traction. Postoperatively, nausea and/or vomiting was absent in 93% of cases, 57% of whom had not had antiemetic therapy intraoperatively. Postoperative pain scores of zero were recorded in 88% of cases, with the use of simple analgesics (paracetamol/codeine) or no analgesics recorded in 43% and 36%, respectively (for the entire hospital stay). Discharge home was on the first postoperative day in 76% of cases. Significant peri-operative complications were as follows: one patient suffered a CVA two days postoperatively and a CSF leak developed intra-operatively in another case (this resolved within 24 h and according to protocol a lumbar drain was inserted). Infraorbital anaesthesia was experienced in five cases (9%) (with complete resolution of symptoms after several months) and diplopia developed (15%) or worsened (22%) overall in 37% of cases. In our experience, anaesthesia for surgical decompression of the orbit is generally safe, has a low incidence of postoperative pain and nausea and vomiting and requires only a short hospital stay. However, one must be aware of the need to provide anaesthesia of long duration, and of the high incidence of pre-operative morbidities, smoking and high-dose steroid therapy.

FEWER NURSING INTERVENTIONS AND LOWER SYMPTOMS FREQUENCY AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH NERVE BLOCK ANALGESIA

S284 INTRODUCTION: In this study, we examined outpatients undergoing anterior cruciate ligament reconstruction (ACLR), and the influence of various anesthesia clinical pathways (with and without femoral nerve block analgesia) on the incidence of pain and postoperative nausea and vomiting (PONV). We also tabulated the number of nursing interventions required for these common postoperative symptoms. Our hypothesis was that anesthetics incorporating a femoral nerve block led to less postoperative pain and regional anesthetics led to less PONV than did general anesthesia. METHODS: We queried our institution's database for 701 ACLR patients over 3 years (from July 1995 through June 1998). Based on the patient's medical record, we tabulated the number of required nursing interventions throughout recovery for pain, nausea, and vomiting. We considered the number of postoperative nursing interventions a quality indicator of the intraoperative anesthetic delivered, with respect to the anesthesia care team's management of the anesthetic process consistent with goals of the anesthesia clinical pathway. The incidence of pain, PONV, and the number of required nursing interventions were the dependent variables. The specific anesthesia techniques (and/or clinical pathways used) were the independent variables. One-way analysis of variance (ANOVA) was used to identify differences in required nursing interventions; differences between specific groups were determined using the Bonferroni adjustment for multiple comparisons. The independent-sample t-test was used for pairwise comparisons, when appropriate. Binomial variables (the incidence of pain and PONV) were analyzed using the chi-squared test. For all statistical tests, P < 0.05 was considered significant. RESULTS: All patient data entered into the ACLR database were subject to this analysis. The incidence of pain and PONV after general anesthesia (GA) was 61% and 37%, respectively. Combined regional anesthesia (RA) and GA (CRG) significantly reduced the incidence of pain to 30% (P<0.001), but did not lead to a significant reduction in the incidence of PONV (35%). RA (without GA) led to lower incidences of pain (19%, P=0.007) and PONV (14%, P<0.001) than did combined GA-RA. RA designed to include prolonged femoral nerve block analgesia led to a lower incidence of postoperative pain (13%) than did RA without prolonged femoral nerve block analgesia (27%, P=0.002). There were no significant differences in the incidence of PONV based on the presence or absence of femoral nerve block analgesia superimposed upon an intraoperative regional anesthetic. GA led to the most postoperative nursing interventions (2.5 +/- 0.4), while both RA and combined GA-RA led to significantly fewer interventions than did GA. The difference in the number of interventions for RA (0.7 +/- 0.3) and CGR (1.0 +/- 0.3) was not significant. DISCUSSION: This study examined a complex and painful outpatient procedure (arthroscopic ACLR) and found that a standardized GA technique (in 1996-1997) led to equally unacceptable outcomes as did a non-standardized GA technique (in 1995-1996) in historical controls. Only when the femoral nerve block was added to these GA techniques did the incidence of pain improve. Our shift of intraoperative care from GA to RA, from 1995-96 to 1997-98, led to a lower incidence of inhospital PONV. Intraoperative RA with femoral nerve block analgesia has led to less pain (but no less postoperative PONV) than RA without femoral nerve block analgesia.