Lower Postoperative Pain Scores Research Articles

Lightweight versus Heavyweight mesh for open repair of inguinal hernia

Background Open repair of inguinal hernia with mesh is associated with a decreased risk of recurrence compared to hernia repair without mesh. However, the use of traditional heavyweight (HWM) polypropylene mesh in hernia repair has raised concerns about the higher incidence of postoperative chronic groin pain, persistent groin discomfort, foreign body sensations, testicular atrophy and impaired sensations in the groin. Lightweight mesh (LWM) is composed of a reduced component of reactive biomaterial and is considered an innovative measure to lessen the long term consequences of the mesh repair of inguinal hernia. Objectives The objective of this review is to systematically analyse the randomised, controlled trials (RCTs) to compare the effectiveness of LWM versus HWM in patients undergoing open inguinal hernia repair. Search methods The Cochrane Colorectal Cancer Group (CCCG) Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (Issue 1, 2012), MEDLINE (until March 2012), EMBASE (The Intelligent Gateway to Biomedical & Pharmacological Information until March 2012), and Science Citation Index Expanded (SCI-E until March 2012) using the medical subject headings (MeSH) terms were searched without date, language or age restrictions. Selection criteria RCTs comparing the effectiveness of LWM versus HWM in patients undergoing open inguinal hernia repair. Data collection and analysis At least two review authors independently scrutinised search results, selected eligible studies and extracted the data. This data was further confirmed by the third review author to check the accuracy. Main results Fourteen published articles on eleven RCTs encompassing 2589 patients undergoing open inguinal hernia repair either using LWM or HWM were retrieved from the electronic databases. There were 1282 patients in the LWM group and 1307 patients in the HWM group. Statistically, there was no difference between LWM and HWM in terms of duration of operation, postoperative complications, the risk of hernia recurrence and the risk of developing testicular atrophy. LWM was associated with lower postoperative pain score, early return to work and daily activities. In addition, LWM was associated with the reduced risk of developing chronic groin pain and the reduced risk of developing other groin symptoms such as groin discomfort, sensory impairment, regional hard feelings, point tenderness and foreign body sensations. Authors' conclusions LWM may not increase the risk of inguinal hernia recurrence. LWM seems to be associated with the reduced risk of developing chronic groin pain and other symptoms such as groin discomfort, sensory impairment, regional hard feelings, point tenderness and foreign body sensations. These outcomes should better be judged after long-term follow up and therefore, LWM may only be considered a viable alternative to HWM in open inguinal hernia repair instead of recommending its routine use.

Natural Orifice Specimen Extraction Surgery versus Conventional Laparoscopic-Assisted Resection in the Treatment of Colorectal Cancer: A Propensity-Score Matching Study.

BackgroundNatural orifice specimen extraction surgery (NOSES) has been successfully applied to the treatment of gastric, colorectal cancer (CRC). However, the development of NOSES is still in the exploratory stage, and there is still no strong evidence-based medical evidence.Patients and MethodsFrom January 2013 to June 2017, consecutive patients with colorectal cancer who underwent transluminal resection, anastomosis, and specimen extraction and those who underwent conventional laparoscopic resection were enrolled. Propensity score matching was used to align clinicopathological features between the two groups.ResultsA total of 372 patients were eventually included in this study, 186 in each group. According to perioperative information and postoperative follow-up in both groups, the NOSES group had less blood loss (P = 0.011), shorter time to recovery of gastrointestinal function (P < 0.001), shorter postoperative hospital stay (P = 0.037). The NOSES group had fewer postoperative analgesics (P < 0.001), lower postoperative pain scores (P < 0.001), and lower incidence of postoperative complications (P = 0.017). Compared with the LA (laparoscopic) group, the NOSES group had better physical function (P<0.05), role function (P<0.001), emotional function (P<0.001) and global health status than LA group, while symptoms such as pain (P<0.001), insomnia (P<0.001), constipation (P<0.001) and diarrhea (P<0.05) were less severe in the NOSES group. In addition, the NOSES group had higher body image scores. Overall survival (OS) and disease-free survival (DFS) were not significantly different between the two groups.ConclusionFor surgical treatment of colorectal cancer, NOSES has advantages in reducing postoperative pain, recovery of gastrointestinal function, postoperative quality of life, and improving patients’ satisfaction with abdominal wall aesthetics. There was no difference in long-term survival between NOSES and conventional laparoscopic surgery.

Clinical Outcomes and Effectiveness of Laser Treatment for Hemorrhoids: A Systematic Review.

Laser treatment is increasingly used in the treatment of symptomatic hemorrhoids, and several studies have attempted to describe its clinical outcomes. In this systematic review, we aimed to comprehensively analyze the clinical outcomes and effectiveness of laser treatment. We performed a systematic review of currently available data on laser treatment for hemorrhoids. We searched MEDLINE and Google Scholar between January 2009 and May 2020. Studies that described the clinical outcomes and effectiveness of laser treatment were selected based on pre-specified inclusion criteria with a minimum follow-up period of 3months. Qualitative synthesis of the clinical outcomes, effectiveness and complications was performed. Nineteen studies including 1937 patients were analyzed. The majority were males (n = 1239) and included grade 2 and 3 hemorrhoids. In the majority (n = 1750, 90.34%), the 980nm wave length diode laser was used as the energy source. Doppler-guided localization was performed in six studies (n = 579, 29.89%). All studies (n = 1937) reported low postoperative pain scores and nine studies (n = 1131) showed significantly lower pain compared to open technique. Furthermore, six studies (n = 1023) showed significantly less intra- and postoperative bleeding compared to open technique. Seven studies (n = 1052) reported long-term follow-up results and were found to be satisfactory in terms of symptom relief and recurrence. This study was limited by heterogeneity of outcomes precluding a meta-analysis. Laser treatment had acceptable clinical outcomes for grade 2 and 3 hemorrhoids with lower rates of postoperative pain and bleeding with satisfactory long-term outcomes.

Circumcision in children: postoperative analgesic efficiency of transversus abdominis plan block vs caudal epidural block: a prospective observational study

Background and objective: Circumcision is one of the most common operations and can cause postoperative pain, fear, and anxiety for children. This study aims to compare the effects of transversus abdominis plane (TAP) block and caudal epidural (CE) anesthesia on postoperative analgesia after circumcision in providing postoperative pain control. Methods: Eighty boys aged 1 to 14 years who underwent elective circumcision surgery under general anesthesia either with USG-guided TAP block or with CE block for postoperative analgesia were enrolled consecutively to this prospective observational study equally in each group. Postoperative pain scores and need for rescue analgesia were recorded and compared between the two groups. Results: There was no statistically significant difference between the groups in mean age and Aldrete scores (p &gt; 0.05). Body mass index (BMI) of the caudal block group was statistically lower than the TAP group (p &lt; 0.05). While there was no statistically significant difference between the groups in 30th-minute VAS values (p &gt; 0.05), the CE block group's 1st, 2nd, 4th, 8th, 12th, 18th, and 24th hour VAS values were statistically lower than the TAP block group's (p &lt; 0.05). Conclusion: USG-guided TAB block under general anesthesia was not associated with lower postoperative pain scores and delayed rescue analgesia need compared with CE block in patients who underwent elective circumcision surgery. CE block provided superior analgesia than the USG-guided TAP block after elective circumcision surgery in this study.

Duration of Cessation of Smoking before Elective Surgery: Impact on Intraoperative Hemodynamics and Early Postoperative Pain in Developing Country

Aim and Background: It is estimated that up to 20% of patients coming for elective surgery are smokers and carry a risk of perioperative complications. Though smoking cessation and its impact on perioperative outcome are widely investigated worldwide we were unable to find any data in Pakistan. The objective of the study is to determine the impact of the duration of smoking cessation before elective surgery on intraoperative hemodynamics and postoperative pain in Pakistani population. Methods: It was a prospective cohort study conducted at the Aga Khan University Hospital Karachi, Pakistan, for one-year duration. A total of 260 patients scheduled for elective noncardiac surgery under general anaesthesia were recruited. Surgery under regional anaesthesia and minor surgery under general anaesthesia were excluded. Data on self-reported duration of smoking cessation by patients, intraoperative haemodynamics, postoperative pain scores and duration of hospital stay were collected by independently trained data collectors from the preoperative area until the patient is discharged from the hospital. Results: A data from 256 patients were analyzed. On the basis of self-reported duration of preoperative smoking cessation, patients were divided into 4 groups (Group 1: less than 2 days, Group 2: more than 2 days to 7 days, Group 3: more than 7 days to 4 weeks and Group 4: more than 4 weeks). It was found that the longer the duration of cessation of smoking is the less haemodynamic changes and lower postoperative pain scores. Length of stay did not show any difference among all four groups. No major postoperative pulmonary complication was found in any study patient. Conclusions: Duration of cessation of smoking before elective surgery is a significant predictor of intraoperative haemodynamics and early postoperative pain in Pakistani population. A short duration of smoking cessation also helps to avoid some of the adverse effects and reduces perioperative complications.

Intraoperative Dexmedetomidine for Analgesia during Burn Excision and Grafting

Abstract Patients with superficial burns normally do not require surgical intervention, however, burns that are deep and large, require numerous procedures for excision and skin grafting (EG).1 Consequently, the complicated care of these patients is often transferred into the hands of their anesthesia providers. One of the challenges with these patients lies in their multi-faceted, but common theme of pain, which is confounded not only by high inter-patient variability and unpredictability1, 2 , but by pain from the initial injury, by wound care pain and by the new, postoperative pain from EG procedures.1 Furthermore, because of tolerance and hyperalgesia, increasing doses of narcotics may be required and yet fail to provide adequate relief and sadly, ineffective pain control can be associated with poor emotional health including, but not limited to, depression and post-traumatic stress disorder.1,2,3 Clearly, the complexity of burns requires a thoughtful approach to analgesia. This case report details the utilization of dexmedetomidine as an adjunct for analgesia during EG for a severely burned patient. Anesthetic technique as well as immediate postoperative course for similar EG procedures were compared but limited to 5 procedures over a 20-day timeframe. The anesthetic specific to this case report was the only anesthetic in which Dexmedetomidine was utilized. Findings are consistent with the evidence and reveal on the day Dexmedetomidine was used, the patient had lower post-operative pain scores, lower postoperative Richmond Agitation Sedation Scores (RASS), and it was the only day the patient did not require any postoperative PRN pain medication administration. Although limited evidence exists specifically related to the use of intraoperative dexmedetomidine for EG of severe burns, this case report suggests a promising role for the addition of this a2 agonist as a multi-modal approach to caring for this complex population. References Ray DE, Karlekar MB, Crouse DL, et al. Care of the critically ill burn patient. Ann Am Thorac Soc. 2017;12(7):1094-1102. DOI: 10.1513/AnnalsATS.201607-577PS Retrouvey H, Shahrokhi S. Pain and the thermally injured patient—A review of current therapies. Journal of Burn Care &amp; Research. 2015;36(2):315-323. DOI: 10.1097/BCR.0000000000000073 Bittner E, Shank E, Woodson L, Martyn J. Acute and perioperative care of the burn-injured patient. Anesthesiology. 2015;122(2):448-464. DOI: 10.1097/ALN.0000000000000559

Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery.

Spine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate. Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care. Of 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference -1.22 days [95% CI -1.98 to -0.47]) and lumbar spine ERAS protocols (-1.53 days [95% CI -2.89 to -0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use. Present data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.

Effects of virtual reality on relieving postoperative pain in surgical patients: A systematic review and meta-analysis.

Postoperative pain is a prevalent problem leading to many adverse outcomes in surgical patients. Virtual reality (VR) is an emerging non-pharmacological method of postoperative pain relief, but the effects of it are not clear. This review aimed to explore the effects of VR on relieving postoperative pain. Studies published up to November 2019 were identified by searching the PubMed (Medline), Embase, Web of Science, and other databases. Meta-analyses were conducted to compare VR and usual care for relieving postoperative pain. Subgroup analyses and sensitivity analyses were performed to explain the heterogeneity. Overall, 8 randomized control trials (RCTs) enrolling 723 participants were included. Our results demonstrated that the patients receiving the VR intervention had lower postoperative pain scores than those receiving the usual care (mean difference [MD] -0.64; 95% CI -1.05 to -0.22; P=0.002). One subgroup analysis revealed that VR could relieve postoperative pain both in minor surgery (MD -1.48; 95% CI -2.02 to -0.95; P<0.0001) and major surgery (MD -0.32; 95% CI -0.53 to -0.11; P<0.03). Another subgroup analysis demonstrated a significant reduction in postoperative pain among patients receiving VR during the intraoperative (MD -1.51; 95% CI -2.04 to -0.97; P<0.00001) and the postoperative periods (MD -0.50; 95% CI -0.76 to -0.24; P=0.002). However, there was no significant postoperative pain relief when receiving VR during the preoperative period. Additionally, significant improvements in postoperative satisfaction were reported in two studies. However, another two studies included found that VR could not affect physiological parameters related to pain. Applying VR can relieve postoperative pain effectively. The type of surgery and timing of using VR are the main sources of heterogeneity. More rigorous studies about the relationship between VR and postoperative pain relief will be needed.

Verification of clinical applicability of the non-special perioperative administration for enhanced recovery after surgery of gastric cancer patients: a Chinese single-center observational report

Objective: To verify clinical applicability of the non-special perioperative administration for enhanced recovery after surgery (ERAS) proposed by Japanese scholars in Chinese gastric cancer patients. Methods: The main measures of the non-special perioperative administration for ERAS are as follows: (1) discussion of multiple disciplinary team before surgery; (2) rehabilitation education for patients; (3) no routine bowel preparation before surgery; (4) placement of nasogastric tube for decompression routinely before operation and removal as early as 24 hours after surgery; (5) appropriate rehydration; (6) antibiotic prophylaxis before surgery; (7) place abdominal drainage tubes when necessary; (8) epidural patient-controlled analgesia and oral medication for postoperative pain management; (9) start low-molecular-weight heparin injection 48h after surgery and ambulation every day to prevent deep vein thrombosis; (10) postoperative dietary management and supplement with parenteral nutrition intermittently; (11) remove Foley catheter about 24 hours after surgery. A retrospective cohort study was performed, including 203 patients undergoing radical gastrectomy at Department of Gastroenterology, Tianjin Medical University Cancer Institute and Hospital from January 2017 to December 2018. Inclusion criteria were patients who were ≤75 years old without distant metastasis by preoperative examination, were diagnosed as gastric adenocarcinoma by postoperative histopathology and had complete clinicopathological and follow-up data. Patients with history of other malignancies and gastrectomy, extensive implantation of the abdominal cavity or malignant ascites by intraoperative exploration, death within 1 month after surgery, and residual gastric cancer were excluded. The perioperative management methods were chosen by patients. There were 123 patients who followed non-special perioperative administration for ERAS (non-special preparation group) and 80 patients who underwent traditional perioperative management (traditional method group). The primary outcomes (postoperative hospital stay, time to the first flatus, time to the first fluid diet, time to the first ambulatory activity, morbidity of postoperative complication, mortality, and readmission rate) and secondary outcomes (operative time, intraoperative blood loss and postoperative pain score) were compared between the two groups. Results: Compared to the traditional method group, the non-special preparation group had shorter time to the first flatus [(3.6±1.1) days vs. (4.8±1.4) days, t=3.134, P=0.003], shorter time to the first liquid diet [(2.6±0.9) days vs. (5.5±1.6) days, t=15.105, P<0.001], shorter time to the first ambulatory activity [(1.9±0.5) days vs. (4.1±1.1) days, t=8.543, P<0.001] and shorter postoperative hospital stay [(9.6±2.3) days vs. (12.9±2.3) days, t=5.020, P<0.001]. Besides, incidences of pancreatic leakage [6.5% (8/123) vs. 16.3% (13/80), χ(2)=4.964, P=0.026], lymphatic leakage [1.6% (2/123) vs. 13.8% (11/80), χ(2)=11.887, P=0.001], peritoneal effusion [2.4% (3/123) vs. 10.0% (8/80), χ(2)=4.032, P=0.045], and gastroparesis [0.8% (1/123) vs. 7.5% (6/80), χ(2)=4.657, P=0.031] in the non-special preparation group were significantly lower. The overall morbidity of postoperative complications and incidences of pulmonary infection and intestinal adhesion were not significantly different between the two groups (all P>0.05). As for the secondary outcomes, compared to the traditional method group, the non-special preparation group had less intraoperative blood loss [(80.4±24.4) ml vs. (100.5±19.4) ml, t=3.134, P=0.003] and lower postoperative pain score [postoperative day 1: (4.4±0.3) vs. (5.3±0.8), t=2.504, P=0.037],while the difference in operative time was not significant (P>0.05). Conclusion: The non-special perioperative administration for ERAS proposed by Japanese scholars is effective and safe, which has certain clinical applicability and value for Chinese patients with gastric cancer.

An analysis of the \u201cHalf-Perc\u201d versus open surgical placement method for a peritoneal dialysis catheter: a non-inferiority cohort study

BackgroundMost end-stage renal disease (ESRD) patients undergo open surgical techniques for peritoneal dialysis (PD) catheter placement. An alternative method to PD catheter implantation is the half-percutaneous (“Half-Perc”) technique based on a modified trocar that is performed by a nephrologist. The single-center, retrospective, observational, cohort study presented here aimed to compare the effects of the “Half-Perc” technique with the traditional open surgery on peritoneal catheter insertion.MethodsFrom January 2015 to January 2018, 240 ESRD patients who received initial PD catheter placement were divided into two groups based on the “Half-Perc” technique or open surgery. All patients were followed up for 365 days or until loss of initial PD catheter or death. Prism 5 software was used to analyze baseline characteristics, operation-related parameters, mechanical complications and clinical outcomes.ResultsThe “Half-Perc” technique showed shorter operation time, shorter incision length, lower postoperative pain scores and quick initiation of the PD program compared to the open surgery. After the 365-day follow-up, the “Half-Perc” group showed a higher rate of catheter dysfunction (4% versus 0.9%) that was corrected by conservative treatment in most patients and a lower rate of peritonitis (4% versus 9.6%) but mechanical complications and clinical outcomes did not differ between the two groups. There was also no significant difference based on overall patient mortality or catheter removal. One-year initial catheter survival and true catheter survival were not statistically different between the groups.ConclusionThe “Half-Perc” placement of the PD catheter using a modified metal trocar appears to be a non-inferior alternative method and carries minimal invasiveness and risk compared to open surgical placement.

Efficacy of Adductor Canal Block Combined With Additional Analgesic Methods for Postoperative Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study

BackgroundThe aim of this study is to evaluate the efficacy of adductor canal block (ACB) combined with additional analgesic methods in total knee arthroplasty (TKA) and investigate whether blocking the sensory nerves that are distributed in the posterior and lateral aspect of knee could improve postoperative pain control. MethodsTwo hundred scheduled patients for TKA were randomly allocated into 4 groups: Group A received ACB combined with iPACK (interspace between the popliteal artery and capsule of the knee) block and lateral femoral cutaneous nerve block (LFCNB); Group B received ACB combined with iPACK block; Group C received ACB combined with LFCNB; and Group D received ACB only. Postoperative pain score was the main primary outcome. Secondary outcomes included the morphine consumption and analgesic duration. Other outcomes included knee range of motion, quadriceps strength, ambulation, Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index physical function, timed up and go (TUG) test, and complications. ResultsGroups A, B, and C had lower postoperative pain scores within 12 hours at rest and 8 hours with activity than Group D (P < .05). In addition, Group A had lower morphine consumption than both Group C (P < .05) and Group D (P < .01). Group A had the longest analgesic duration (19.21 ± 3.22 hours) among all groups. There were no significant differences among the groups in terms of mobility and complication after surgery. ConclusionCombining ACB with both iPACK and LFCNB is an effective method for decreasing early postoperative pain in TKA without increasing the complications or affecting the early rehabilitation.

Less is more: clinical impact of decreasing pneumoperitoneum pressures during robotic surgery.

The objective of this study was to investigate the effects of decreasing insufflation pressure during robotic gynecologic surgery. The primary outcomes were patient-reported postoperative pain scores and length of stay. Secondary outcomes include surgical time, blood loss, and intraoperative respiratory parameters. This is a retrospective cohort study of patients undergoing robotic surgery for benign gynecologic conditions by a single minimally invasive surgeon at an academic hospital between 2014 and 2017. Patients were categorized by the maximum insufflation pressure reached during the surgery as either 15, 12, 10, or 8mmHg. Continuous variables were compared using analysis of variance and χ2 test was used for categorical variables. 598 patients were included in this study with no differences in age, BMI, race, prior abdominal surgeries, or specimen weight between the four cohorts. When comparing cohorts, each decrease in insufflation pressure correlated with a significant decrease in initial pain scores (5.9 vs 5.4 vs 4.4 vs. 3.8, p ≤ 0.001), and hospital length of stay (449 vs 467 vs 351 vs. 317min, p ≤ 0.001). There were no differences in duration of surgery (p = 0.31) or blood loss (p = 0.09). Lower operating pressures were correlated with significantly lower peak inspiratory pressures (p < 0.001) and tidal volumes (p < 0.001). Surgery performed at lower-pressure pneumoperitoneum (≤ 10mmHg) is associated with lower postoperative pain scores, shorter length of stay, and improved intraoperative respiratory parameters without increased duration of surgery or blood loss. Operating at lower insufflation pressures is a low-cost, reversible intervention that should be implemented during robotic surgery as it results in the improved pain scores and shorter hospital stays.

Laparoscopic versus open appendicectomy: a non-randomized comparative study

Background: Appendicectomy is one of the most common surgical procedures performed in emergency surgery. Despite this, there is still lack of consensus about the most appropriate technique for appendicectomy. In this longitudinal analysis, we aimed to compare the outcomes of laparoscopic appendicectomy (LA) and the conventional technique or open appendicectomy (OA) in the treatment of acute appendicitis.Methods: A non-randomized longitudinal comparative study was conducted in NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, India. From November 2017 to October 2019, 53 patients underwent OA and 59 underwent LA, making a total number of patients included in this study to be 112 (n). The two groups were compared for operative time, length of hospital stay, postoperative pain, post-operative ileus and complication rate.Results: Laparoscopic appendicectomy was associated with a shorter hospital stay (4.34±1.37 days in LA and 5.09±1.71 days in OA, p&lt;0.01), with a lower post operative pain score [VAS] (2.93±0.80 in LA and 4.62±0.92 in OA, p&lt;0.001). Operative time was shorter in the open group (42.70±12.05 min in OA and 43.39±16.59 in LA). Complications were lesser in the LA group with a significantly lower incidence of wound infection (3.4% in LA and 13.2% in OA).Conclusions: Laparoscopic approach is safe and efficient in appendicectomy and it provides clinically advantages over open method (shorter hospital stays, lower post op pain, early food tolerance, earlier return to work and lesser wound infection) against only marginally longer operative time.

Raised Adenosine and Adenosine Deaminase in Bladder Cancer Require Less Postoperative Analgesia Compared with Benign Prostatic Hyperplasia After Transurethral Resection

Transurethral resection of the prostate (TUR-P) and transurethral resection of bladder tumor (TUR-BT) are common urological operations. Our aim was to show whether there was an association of the adenosine molecular pathway with postoperative pain level and malignancy status. A total of 93 patients with ages between 55 and 72 years old who underwent TUR-P (n = 47) and TUR-BT (n = 46) under spinal anesthesia between August 2017 and July 2018 were retrospectively analyzed. On the day of surgery, at the postoperative 24th and 48th hours, plasma adenosine levels and serum adenosine deaminase (ADA) levels were measured. The malignant group had significantly higher adenosine (median 171.51 IQR = 147.69–196.32 vs. median 57.82, IQR = 54.06–62.34, p < 0.001) and ADA levels (median 19.10, IQR = 12.85–22.05 vs. median 7.00, IQR = 5.80–10.80, p < 0.001) preoperatively. Although their levels decreased at the postoperative 24th and 48th hours, the levels remained significantly higher in the malignant group until the postoperative 24th hour (p < 0.001). Lower pain level during the first 36 h and less analgesic requirement during the first 24 h were observed in the malignant group (p < 0.001). In addition, patients with higher tumor grades experienced less pain up to the postoperative 6th hour (p < 0.016). A strong positive correlation was observed between adenosine and ADA levels before surgeries for all patients (rho = 0.637, p < 0.001). There were also negative correlations between VAS score and adenosine level (rho = − 0.721, p < 0.001) or VAS and ADA (rho = − 0.658, p < 0.001). In multivariate analysis, preoperative adenosine level (OR = 4.742, p < 0.001) was found to be the most important parameter affecting postoperative non-opioid analgesic requirement. According to our preliminary results, lower postoperative pain scores and less additional analgesic requirement may be associated with an increase in endogenous adenosine levels in malignant cases.

Perioperative Continuation of Buprenorphine at Low-Moderate Doses Was Associated with Lower Postoperative Pain Scores and Decreased Outpatient Opioid Dispensing Compared with Buprenorphine Discontinuation.

An increasing number of individuals are prescribed buprenorphine as medication-assisted treatment for opioid use disorder. Our institution developed guidelines for perioperative buprenorphine continuation with an algorithm for dose reduction based upon the surgical procedure and patient's maintenance dose. The objective of this study was to compare the effects of buprenorphine continuation with those of discontinuation on postoperative pain scores and outpatient opioid dispensing. Retrospective observational study. Surgical patients on buprenorphine from March 2018 to October 2018. Patients on buprenorphine for chronic pain and those with minor procedures were excluded from analysis. We compared postoperative outpatient opioid dispensing and postanesthesia care unit (PACU) pain scores in patients where buprenorphine was continued compared with held perioperatively, collecting single surgical subspecialty prescriber data on outpatient full mu-opioid agonist prescriptions dispensed, converted into mean morphine equivalents. Buprenorphine formulations were not included in our morphine milligram equivalents (MME) total. There were 55 patients total (38 cont. vs 17 held). There was no difference in postoperative buprenorphine treatment adherence (91% cont. vs 88% held, P = 0.324). The number of opioid prescriptions dispensed was significantly higher with buprenorphine discontinuation (53% cont. vs 82% held, P = 0.011), as was MME dispensed (mean of 229 cont. vs mean of 521 held, P = 0.033). PACU pain scores were higher with buprenorphine discontinuation (mean 2.9 cont. vs mean 7.6 held, P < 0.001). There was a significant reduction in opioid prescriptions filled, MME dispensed, and PACU pain scores in patients where buprenorphine was continued vs held perioperatively. We provide evidence to support that buprenorphine can be continued perioperatively and that continuation is associated with decreased postoperative pain and decreased outpatient opioid dispensing. These results contribute to the existing literature supporting the perioperative continuation of buprenorphine.

The Safety and Efficacy of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Laryngologic Surgery.

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is an intraoperative ventilatory technique that allows avoidance of tracheal intubation (TI) or jet ventilation (JV) in selected laryngologic surgical cases. Unimpeded access to all parts of the glottis may improve surgical precision, decrease operative time, and potentially improve patient outcomes. The objective of this prospective, randomized, patient-blinded, 2-arm parallel pilot trial was to investigate the safety and efficacy of THRIVE use for adult patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration. Twenty adult, American society of anesthesiology class 1-3 patients with body mass index (BMI) < 35 kg/m2 were randomly assigned to either an experimental THRIVE group or active comparator conventional ventilation group (TI or supraglottic high-frequency JV [SHFJV]). Primary outcomes included intraoperative oxygenation, anesthesia awakening/extubation time, time to laryngoscopic suspension, number of intraoperative suspension adjustments, and operative time. Secondary patient outcomes including postanesthesia and functional patient recovery were investigated. Compared to TI/SHFJV, THRIVE use was associated with significantly lower intraoperative oxygenation (SpO2 93.0 ± 5.6% vs. 98.7 ± 1.6%), shorter time to suspension (1.8 ± 1.1 minutes vs. 4.3 ± 2.1 minutes), fewer suspension adjustments (0.4 ± 0.5 vs. 1.7 ± 0.9), and lower postoperative pain scores on recovery room admission (1.3 ± 1.9 vs. 3.7 ± 2.9) and discharge (0.9 ± 1.3 vs. 2.7 ± 1.8). The study was underpowered to detect other possible outcome differences. We confirm the safe intraoperative oxygenation profile of THRIVE for selected patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration. THRIVE facilitated surgical exposure and improved early patient recovery, suggesting a potential economic benefit for outpatient laryngologic procedures. The results of this exploratory study provide a framework for designing future adequately powered THRIVE trials. ClinicalTrials.gov (NCT03091179). II Laryngoscope, 2020.

The effectiveness of preoperative individual information on reducing anxiety and pain after hysterectomy: A randomized controlled trial

Background and objective: Preoperative anxiety among gynecological patients is well-known and has a direct correlation with postoperative pain. By minimizing preoperative anxiety, the level of postoperative pain may decrease. The purpose of this study was to evaluate the effect of preoperative structured information and dialogue on patients' anxiety and postoperative pain.Methods: A single-center non-blinded randomized controlled trial. Forty-six women scheduled for hysterectomy were allocated either to the study group or the control group. The study group was given individual information at a preoperative consultation while the control group was given information at admittance. The main outcome was anxiety level and postoperative pain.Results: Forty participants (study group = 20; control group = 20) were analyzed. No statistically significant difference was found in anxiety level within the first 24 h postoperatively or in postoperative pain within four weeks between the groups.Conclusions: Preoperative individual information and dialogue did not result in significant effects in reducing anxiety level nor did it result in lower postoperative pain score.

Safety and efficacy of clonidine on postoperative vomiting and pain in pediatric ophthalmic surgery: A systematic review and meta-analysis.

Postoperative vomiting and pain are common, unpleasant phenomena in pediatric patients undergoing ophthalmic surgery. Clonidine has antiemetic and analgesic properties and thus may be used as premedication to reduce postoperative vomiting and pain. To assess whether clonidine premedication may safely decrease postoperative vomiting and postoperative pain in pediatric patients who received an ophthalmic surgery. We systematically searched PubMed, EMBASE, Cochrane Library, and Scopus databases from their inception to September 2018. Randomized clinical trials comparing clonidine premedication with a placebo or an active comparator that investigated postoperative vomiting or postoperative pain in pediatric patients undergoing ophthalmic surgery were included. The primary outcome was postoperative vomiting. The secondary outcome was postoperative pain. We also evaluated the safety of clonidine premedication by tracking hemodynamic instability associated with its use. Ten studies with 979 patients were eligible for inclusion. Clonidine achieved a significantly lower incidence of postoperative vomiting within 6hours postoperatively, 6-24hours postoperatively, and at the end of the study (risk difference: -0.15; 95% confidence interval: -0.32 to -0.05; risk difference: -0.15; 95% confidence interval: -0.29 to 0.01; and risk difference: -0.23; 95% confidence interval: -0.34 to -0.12, respectively) than placebo. For the subgroup of patients who received strabismus surgery, clonidine produced a lower incidence of postoperative vomiting than placebo (risk difference: -0.19; 95% confidence interval: -0.29 to -0.05). Compared to benzodiazepine, clonidine achieved a lower incidence of postoperative vomiting at the end of the study (risk difference: -0.19; 95% confidence interval: -0.31 to -0.07); the effect was only observed in patients receiving clonidine 4μg/kg. Furthermore, children receiving clonidine had lower postoperative pain scores, lower analgesic requirements, and more of them were pain-free compared to those who received a placebo. No patient using clonidine had any major hemodynamic instability. Compared to placebo or benzodiazepine, clonidine premedication was effective in reducing postoperative vomiting in pediatric patients undergoing ophthalmic surgery. Clonidine premedication also provided more reduction in postoperative pain when compared to placebo. The use of clonidine premedication was not associated with adverse hemodynamic events.

A Collaborative Approach to Pain Control Reduces In-hospital Opioid Use and Improves Range of Motion following Total Knee Arthroplasty.

Introduction: Opioid pain medications are commonly prescribed following orthopedic procedures, with overprescribing of these pain medications implicated as a driver of the current opioid epidemic. In an effort to reduce reliance on opioid pain medications, surgeons are relying on periarticular injections or peripheral nerve blocks. The purpose of this study was to compare numerical rating scale (NRS) pain scores and oral morphine equivalents (OMEs) in patients who underwent primary total knee arthroplasty (TKA) with a periarticular injection alone to those who underwent a collaborative approach with a periarticular injection in the posterior tissue and an adductor canal catheter for anterior knee analgesia.Methods: In this study, 236 patients underwent a primary TKA between December 2017 and April 2018. Forty patients received an adductor canal catheter and 196 underwent a periarticular injection alone.Results: We found no difference in patient demographics between the cohorts (p>0.05). The patients that underwent the collaborative approach with a periarticular injection and adductor canal catheter had lower NRS pain scores on post-operative day 0, 1, and 2 (all P≤0.033). These patients demonstrated a reduction of 43% in opioid consumption during the hospitalization (P<0.001). These patients also demonstrated improved range of motion (ROM) (96 vs. 92 degrees) on the day of discharge (P=0.013).Conclusion: This study provides strong evidence that in patients undergoing TKA, the collaborative approach with the adductor canal catheter and periarticular injection is associated with lower post-operative pain scores, fewer total OMEs per hospital day, and a greater ROM arc prior to discharge compared to patients receiving a periarticular injection alone.

POST OPERATIVE PAIN ASSESSMENT AND OPIOID USE FOLLOWING ACL RECONSTRUCTION WITH QUADRICEPS VERSUS HAMSTRING TENDON AUTOGRAFT IN ADOLESCENTS AND YOUNG ADULTS

Background: The culture of opioid abuse in the United States has brought attention to prescribing habits, especially as recent studies identify practices within the post-operative period as a risk factor for the development of opioid dependence in adolescents. The current study sought to explore the concept of post-operative pain control and opioid use following ACL reconstruction (ACLR), one of the most common orthopaedic procedures for adolescents. Because recent adult studies have suggested that use of quadriceps tendon autograft, a graft choice that appears to be growing in popularity, may be associated with lower post-operative pain scores than other graft sources, we additionally investigated an ACLR cohort who received quad tendon autograft (ACLR-Q) and compared their pain scores and opioid use to a cohort with the more commonly used hamstring tendon autograft (ACLR-HS). Methods: Between 2016 and 2018, patients aged 12-25 years who underwent primary ACLR-Q or ACLR-HS by one of three surgeons at tertiary care children’s hospital, were provided a journal to record daily subjective pain level and medication use. To avoid confounder or outliers, patients with a history of diagnosed clinical pain syndrome or underlying psychiatric condition were excluded. Logbooks contained a scale from ‘0-5’ to record pain level prior to each medication use and tables to record information detailing medication consumption. All patients were prescribed Oxycodone, 5 mg, for post-operative pain control. Patient demographics, surgical data, and prescription information were extracted from the electronic medical record. A two-sided t-test was used to evaluate statistical relationships of data between graft types. Results: Logbooks of 54 patients (27 ACLR-Q and 27 ACLR-HS) were collected for analysis. Both cohorts had a similar mean age at time of surgery (ACLR-Q: 16.7 years, range: 12-23; ACLR-HS: 16.8 years, range: 13-21), and preponderance of female subjects (ACLR-Q: 83.3%; ACLR-HS: 81.5%). The mean weight of patients who received the quadriceps tendon autograft (mean: 68.8lbs, range: 47-121) was slightly heavier than for patients who received the hamstring tendon autograft (mean: 62.0lbs, range 49-93), but not to a significant degree (p=0.084). More meniscal injuries were identified in ACLR-HS patients (77.8% vs. ACLR-Q: 48.1%, p=0.024), and treated with a repair procedure more commonly (81% vs. ACLR-Q: 46.2%, p=&lt;0.001), than with meniscectomy (19%; ACLR-Q: 46.2%, p=0.282). Mean length of surgery and tourniquet time were longer in the ACLR-Q (129, 115 minutes) group than ACLR-HS group (80, 54 minutes) (p=&lt;0.001; p=&lt;0.001). While intra-operative nerve blocks were utilized by a similar proportion of both cohorts (ACLR-Q: 88.9%, ACLR-HS: 85.2%, p:0.692), the ACLR-Q group received more adductor canal blocks (89.9% vs. 14.8%, p: &lt;0.001), while the ACLR-HS group received more femoral nerve blocks most frequently (ACLR-Q: 63% vs. 0%, p: &lt;0.001). For the overall study population, the mean number of pills per Oxycodone prescription was 47.5 (range: 30-84). ACLR-Q patients consumed an average of 14.6 opioid pain pills (range: 3-46) over a mean of 13.7 doses (range: 3-36), with the last dose occurring on day 4.4 (range: 1-13). ACLR-HS patients consumed an average of 16.9 opioid pain pills (range: 0-39) over a mean of 14.0 doses (0-36), with the last dose occurring on day 3.7 (range: 0-13). There were no significant differences seen between number of pills consumed (p=0.387), number of doses (p=0.880), or number of days over which opioid medication was taken (p=0.364), between the two cohorts. Subjective pain experience was the same on day of surgery (DOS) for the two graft choices (score: 2.4). Average pain scores increased by the same amount on post-operative day 1 (score: 2.7) for both groups, likely as residual effects from regional anesthetic wore off. By post-operative day 3, average pain scores in the ACLR-Q group (score: 2.3) and ACLR-HS group (score: 2.0) had declined to less than that seen on DOS, without statistical difference (p=0.350) in the pain level between the cohorts. Conclusion/Significance: Despite longer tourniquet and operative times in the ACLR-Q group, which is likely reflective of graft harvest/preparation time and a surgical learning curve associated with a relatively newer technique, adolescents and young adults who received quadriceps and hamstring tendon grafts had a similar profile of subjective pain and use of post-operative opioid medication in the immediate post-operative period. Differing rates of concomitant meniscal injury and regional anesthetic techniques may represent confounding factors that warrant future studies controlling for such factors. Importantly, both reconstructive techniques resulted in a large surplus of unused opioid medication, furthering the notion that evidence-based prescription practices for post-operative care in different surgical techniques is warranted by orthopaedic surgeons and sports medicine physicians to help stem the rising tide of the opioid epidemic.