Postoperative Pain Resolution Research Articles

Characterization of Pain Associated With Pelvic Organ Prolapse: Is Surgery the Answer?

Data on the incidence of pelvic organ prolapse (POP)-related pain, risk factors for its development, and treatment effects of surgery remain sparse. The aims of the study were to evaluate the incidence and characteristics of POP-related pain in patients presenting with POP and assess the outcome of pain after surgery. This was a retrospective study of patients presenting for initial evaluation of POP from May 2019 to May 2020. Using a standardized questionnaire, patients were asked "Do you have pain associated with your prolapse (not pressure or fullness)?" and to indicate pain severity and location(s). Patients who underwent surgery were asked postoperatively if their POP-related pain resolved. Patient and perioperative characteristics were obtained from the medical record and used to evaluate relationships between the presence and resolution of POP-related pain. Of the 795 patients who met inclusion criteria, 106 (13.3%) reported POP-related pain. The mean age of all patients was 59.9 years, 38.1% had stage 3 or greater POP, and 52.1% were sexually active. Women with POP-related pain reported a median severity of 5 of 10. The most common pain locations were the vagina (46.6%), lower abdomen (27.4%), and back (9.6%). Fifty-seven women with pain (53.8%) underwent surgery, and 40 (70.2%) reported postoperative pain resolution. Of those who did not have resolution, pain improved or remained stable in severity. No patients reported worsening pain after surgery. Pain is a symptom experienced by more than 1 in 8 women presenting with POP, with 70% reporting resolution of their pain postoperatively.

Preoperative Versus Perioperative Risk Factors for Delayed Pain and Opioid Cessation After Total Joint Arthroplasty: A Prospective Cohort Study.

The evolution of pre- versus postoperative risk factors remains unknown in the development of persistent postoperative pain and opioid use. We identified preoperative versus comprehensive perioperative models of delayed pain and opioid cessation after total joint arthroplasty including time-varying postoperative changes in emotional distress. We hypothesized that time-varying longitudinal measures of postoperative psychological distress, as well as pre- and postoperative use of opioids would be the most significant risk factors for both outcomes. A prospective cohort of 188 patients undergoing total hip or knee arthroplasty at Stanford Hospital completed baseline pain, opioid use, and emotional distress assessments. After surgery, a modified Brief Pain Inventory was assessed daily for 3months, weekly thereafter up to 6months, and monthly thereafter up to 1year. Emotional distress and pain catastrophizing were assessed weekly to 6months, then monthly thereafter. Stepwise multivariate time-varying Cox regression modeled preoperative variables alone, followed by all perioperative variables (before and after surgery) with time to postoperative opioid and pain cessation. The median time to opioid and pain cessation was 54 and 152days, respectively. Preoperative total daily oral morphine equivalent use (hazard ratio-HR 0.97; 95% confidence interval-CI 0.96-0.98) was significantly associated with delayed postoperative opioid cessation in the perioperative model. In contrast, time-varying postoperative factors: elevated PROMIS (Patient-Reported Outcomes Measurement Information System) depression scores (HR 0.92; 95% CI 0.87-0.98), and higher Pain Catastrophizing Scale scores (HR 0.85; 95% CI 0.75-0.97) were independently associated with delayed postoperative pain resolution in the perioperative model. These findings highlight preoperative opioid use as a key determinant of delayed postoperative opioid cessation, while postoperative elevations in depressive symptoms and pain catastrophizing are associated with persistent pain after total joint arthroplasty providing the rationale for continued risk stratification before and after surgery to identify patients at highest risk for these distinct outcomes. Interventions targeting these perioperative risk factors may prevent prolonged postoperative pain and opioid use.

Varicocelectomy for scrotal pain: Is it effective?

Varicocelectomy is the prevailing management of scrotal pain secondary to varicocele. However, the literature is controversial on this topic. Some data showed that pain may persist after the surgery even if the varicocele is not detected postoperatively. The objectives of the study were to identify the effect of varicocelectomy in patients with chronic scrotal pain, to report the association between the clinical grade and postoperative pain resolution, and to identify the need for a secondary procedure after varicocelectomy to control the pain. This was a retrospective study of 47 patients who underwent varicocelectomy between March 2016 and December 2018. Postoperatively, the pain totally resolved after surgery in 64.3% of patients with scrotal pain; it improved in 21.4%, 11.9% have persistent pain, and the pain got worse in only 2.4%. Our study showed 100% complete resolution or improvement with Grade I, 85.7% in Grade II, and 81.3% in Grade III. In addition, all patients who underwent bilateral varicocelectomy had pain that either completely resolved or improved postoperatively. On the other hand, all patients who had persistent pain or pain worsening postoperatively had unilateral varicocelectomy. An additional intervention for postoperative pain control was needed in only 14% of patients, 7% of them underwent embolization, 4.7% had a cord block, and 2.3% were sent to a pain clinic. Varicocelectomy offers good outcomes in most patients with varicocele-related scrotal pain. The most significant predictor for success was low grade and bilaterality. However, there is a subset of patients whose symptoms will not improve postoperatively. Careful preoperative counseling and expectation management are crucial when discussing surgical options for those patients.

Chronic pain after surgery and trauma: current situation and future directions

Chronic post-surgical pain (CPSP) stands as a major health issue. The unchanged incidence over the last two decades underlines both the failure of predictive models developed until now and the lack of efficacy of common “preventive” strategies (pharmacotherapy and regional analgesic techniques) applied in current clinical practice. The recognition of CPSP as a disease and the release of a common definition of the condition is an important progress in the field. CPSP predictive scores exist but none has presently demonstrated an impact on patient care. New clinical directions based on the resolution of postoperative pain, a complex and highly dynamic process supported by individual pain trajectories, argue for predictive models and preventive strategies extended to the subacute pain period i.e. after hospital discharge.

Prospective Pilot Study of Robotic-Assisted Harvest of the Latissimus Dorsi Muscle: A 510(k) Approval Study with U.S. Food and Drug Administration Investigational Device Exemption.

There are no U.S. Food and Drug Administration (FDA)-approved indications for robotic plastic surgery. This study was designed to demonstrate safety and efficacy of the robotic latissimus dorsi harvest for FDA approval. This prospective, single-arm study was conducted under an investigational device exemption through the FDA for obtaining 510(k) approval. The primary safety endpoint was adverse events attributable to harvest. Primary efficacy endpoints included muscle viability after harvest and conversion to open technique. Secondary endpoints included postoperative pain and upper extremity function. Fifteen patients enrolled, with a mean age of 50 ± 10 years and a mean body mass index of 25 ± 4 kg/m2. There were no adverse events, all muscles were viable after harvest, and there were zero conversions to open procedures. Visual analogue scale scores for pain progressively decreased postoperatively and returned to baseline, indicating resolution of postoperative pain. Physical therapy assessment demonstrated recovery of function in all range-of-movement domains by 36 weeks. There was no difference in function of the operated extremity between baseline and 36 weeks' follow-up for Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire (p = 0.87); QuickDASH Work Module (p > 0.05); and QuickDASH Sports Module (p > 0.05). The use of the da Vinci Robotic Surgical System is safe based on zero adverse events attributable to harvest and efficacious based on 100 percent muscle viability after harvest and zero conversions to open technique. There appears to be little to no long-term functional deficit or pain from muscle harvest. Given these results and their own prestudy guidelines, the robotic latissimus dorsi qualifies for 510(k) submission by Intuitive Surgical and approval by the U.S. FDA. Therapeutic, IV.

Acute Pain Predictors of Remote Postoperative Pain Resolution After Hand Surgery.

IntroductionChronic postsurgical pain (CPSP) is a global issue with high prevalence. This study compared acute pain descriptors among patients undergoing carpal tunnel release (CTR) or trigger finger release (TFR). We hypothesized worst pain intensity on postoperative day (POD) 10 would be best to predict the time to pain resolution.MethodsIn this secondary analysis of a negative, randomized, double-blind placebo-controlled trial, adult veterans undergoing CTR or TFR were enrolled January 2012–January 2014, with data analysis February 2020–October 2020. Participants were randomized to receive minocycline 200 mg or placebo 2 h prior to the operation, then minocycline 100 mg or placebo twice daily for 5 days. The Brief Pain Inventory, assessed daily, captured three pain scores: average and worst pain over the past 24 h, and current pain intensity. Fifteen acute pain descriptors based on the pain scores (clusters, mean, median, pain scores on POD 10, and linear slopes) were compared as predictors of time to pain resolution.ResultsOf 131 randomized participants, 114 (83 CTR, 31 TFR) were included. Average pain over the last 24 h reported on POD 10 best predicted time to pain cessation. Every one-point increase in the average pain score was associated with a 36.0% reduced rate of pain cessation (HR, 0.64, 95% CI 0.55–0.74, p < 0.001). Average pain on POD 10 was significantly associated with the development of CPSP at 90 days (OR 1.74, 95% CI 1.30–2.33, p value < 0.001). The optimal cutoff score for the high-risk group was determined as average pain on POD 10 ≥ 3.ConclusionsThis study validates prior work and demonstrates the importance of assessing pain severity on POD 10 to identify patients at high risk for CPSP who are most likely to benefit from early pain intervention. Future research in diverse surgical cohorts is needed to further validate pain assessment on POD 10 as a significant predictor of CPSP.

Characterisation of pragmatic postoperative PAin Trajectories over seven days and their association with CHronicity after 3 months: a prospective, pilot cohort study (PATCH study)

BackgroundReliable outcome measurement providing information both on early and late postoperative pain outcomes are still lacking. The purpose of this study was: 1) to characterise postoperative pain trajectories according to an innovative pragmatic concept: ideal pain trajectory (rapid and sustained pain relief) vs non-ideal pain trajectories (late, transient, or no pain relief); and 2) to assess the incidence of persistent post-surgical pain (PPSP) and the potential association between non-ideal pain trajectories and PPSP. MethodsThis prospective observational pilot cohort study was performed from March until June 2016. A total of 344 patients undergoing major general surgery were invited to complete a self-assessment of pain intensity using numerical rating scale (NRS; 0 = no pain to 10 = worst pain) from day 1 until day 7 after surgery, in order to establish their pain trajectory. Three months after surgery, patients were screened for PPSP. ResultsRest pain score was analysed in 308 participants. Among them, 210 (68% - 95% CI: 63–73) had an “ideal” pain trajectory, while 98 (32% - 95% CI: 27–37) had “non-ideal” pain trajectories. Three months after surgery, 31% (95% CI: 26–37) reported PPSP. Multivariable analysis showed that “non-ideal” pain trajectories [OR 2.25; (95% CI: 1.26–4.01) P = 0.006] were significantly associated with PPSP. ConclusionsThe present study proposes an innovative pragmatic concept of postoperative pain trajectories: ideal vs non-ideal pain trajectories, providing information both on acute postoperative pain resolution and early identification patients at risk for developing PPSP. Trial registrationNCT02599233; November, 6, 2015, with clinicaltrials.gov.

Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial.

BackgroundPreoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use.MethodsIn this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18–75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively.ResultsOverall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87–1.00; P=0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68–0.92; P=0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40–0.96; P=0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39–0.92; P=0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80–0.98; P=0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89–1.00; P=0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06–1.77; P=0.016).ConclusionSeparate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes.

Factors Associated With Acute Pain Estimation, Postoperative Pain Resolution, Opioid Cessation, and Recovery

Acute postoperative pain is associated with the development of persistent postsurgical pain, but it is unclear which aspect is most estimable. To identify patient clusters based on acute pain trajectories, preoperative psychosocial characteristics associated with the high-risk cluster, and the best acute pain predictor of remote outcomes. A secondary analysis of the Stanford Accelerated Recovery Trial randomized, double-blind clinical trial was conducted at a single-center, tertiary, referral teaching hospital. A total of 422 participants scheduled for thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, or shoulder arthroscopy were enrolled between May 25, 2010, and July 25, 2014. Data analysis was performed from January 1 to August 1, 2018. Patients were randomized to receive gabapentin (1200 mg, preoperatively, and 600 mg, 3 times a day postoperatively) or active placebo (lorazepam, 0.5 mg preoperatively, inactive placebo postoperatively) for 72 hours. A modified Brief Pain Inventory prospectively captured 3 surgical site pain outcomes: average pain and worst pain intensity over the past 24 hours, and current pain intensity. Within each category, acute pain trajectories (first 10 postoperative pain scores) were compared using a k-means clustering algorithm. Fifteen descriptors of acute pain were compared as predictors of remote postoperative pain resolution, opioid cessation, and full recovery. Of the 422 patients enrolled, 371 patients (≤10% missing pain scores) were included in the analysis. Of these, 146 (39.4%) were men; mean (SD) age was 56.67 (11.70) years. Two clusters were identified within each trajectory category. The high pain cluster of the average pain trajectory significantly predicted prolonged pain (hazard ratio [HR], 0.63; 95% CI, 0.50-0.80; P < .001) and delayed opioid cessation (HR, 0.52; 95% CI, 0.41-0.67; P < .001) but was not a predictor of time to recovery in Cox proportional hazards regression (HR, 0.89; 95% CI, 0.69-1.14; P = .89). Preoperative risk factors for categorization to the high average pain cluster included female sex (adjusted relative risk [ARR], 1.36; 95% CI, 1.08-1.70; P = .008), elevated preoperative pain (ARR, 1.11; 95% CI, 1.07-1.15; P < .001), a history of alcohol or drug abuse treatment (ARR, 1.90; 95% CI, 1.42-2.53; P < .001), and receiving active placebo (ARR, 1.27; 95% CI, 1.03-1.56; P = .03). Worst pain reported on postoperative day 10 was the best predictor of time to pain resolution (HR, 0.83; 95% CI, 0.78-0.87; P < .001), opioid cessation (HR, 0.84; 95% CI, 0.80-0.89; P < .001), and complete surgical recovery (HR, 0.91; 95% CI, 0.86-0.96; P < .001). This study has shown a possible uniform predictor of remote postoperative pain, opioid use, and recovery that can be easily assessed. Future work is needed to replicate these findings. ClinicalTrials.gov Identifier: NCT01067144.

Modified Doppler-guided laser procedure for the treatment of second- and third-degree hemorrhoids.

Hemorrhoids are a common anorectal condition with a major medical and socioeconomic impact. Owing to the high incidence of symptomatic hemorrhoids in the adult population together with the risk of complications of traditional surgery, researchers are seeking less invasive methods of hemorrhoidal treatment.The aim of this study was to present our experience with the mini-invasive Doppler guided hemorrhoidal laser procedure (HeLP) in symptomatic 2nd and 3rd degree hemorrhoids with absent or minimal mucosal prolapse. The cohort included 62 patients with symptomatic hemorrhoids who underwent the HeLP at a tertiary medical center in 2014-2016. Data were collected on clinical and perioperative characteristics and outcome. Findings were compared between patients with second- and third-degree hemorrhoids. The cohort included 41 male and 21 female patients of mean age 41.5 years. Fifty-one had bleeding and 11 had hemorrhoidal syndrome. Mean operative time was 16.6 ± 3.7 minutes. A total of 8-12 arterial branches were treated. Patients were discharged home within a mean of 91.95 ± 20.48 minutes and allowed to resume normal activities. Compared to patients with second-degree hemorrhoids, patients with third-degree hemorrhoids had a significantly higher rate of recto-anal repair (18.2% vs 0, p < 0.05), intraoperative bleeding (11.3% vs 5%, p < 0.05), and thrombus formation in the hemorrhoids (11.3 % vs 0, p < 0.01). At the six-month follow-up, no complications were reported, and there was significant improvement in symptoms.Using the visual analog scale, no pain was reported by 82.3% of patients at one week after surgery and 95.2% of patients at one month after surgery. Patients with hemorrhoids treated with Doppler-guided laser had an excellent outcome in terms of resolution of symptoms and postoperative pain. Only Minor short-term complications were noted. Doppler-guided laser seems to be an effective and painless technique for the treatment of symptomatic second- to third grade hemorrhoids with minimal mucosal prolapse.

Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort

Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice. To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation. A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings. Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours. Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year. Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]). Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further research. clinicaltrials.gov Identifier: NCT01067144.

373 - Operative Variables Associated with Postoperative Pain Resolution Following Laparoscopic Essure® Removal

373 - Operative Variables Associated with Postoperative Pain Resolution Following Laparoscopic Essure® Removal

Mitogen-activated protein kinase phosphatase-3 (MKP-3) in the surgical wound is necessary for the resolution of postoperative pain in mice.

Mitogen-activated protein kinase (MAPK) phosphatase-3 (MKP-3) and its substrates (extracellular signal-regulated kinase [ERK] and p38) play an important role in pathophysiological mechanisms of acute postoperative and chronic neuropathic pain in the spinal cord. This study aimed to understand the role of MKP-3 and its target MAPKs at the site of surgical incision in nociceptive behavior. Wild-type (WT) and MKP-3 knockout (KO) mice underwent unilateral plantar hind paw incision. Mechanical allodynia was assessed by using von Frey filaments. Peripheral ERK-1/2 and p38 phosphorylation were measured by Western blot. Cell infiltration was determined using hematoxylin and eosin histological staining. Peripheral phosphorylated ERK-1/2 (p-ERK-1/2) inhibition was performed in MKP-3 KO mice. In WT mice, mechanical hypersensitivity was observed on postoperative day 1 (0.69±0.17 g baseline vs 0.13±0.08 g day 1), which resolved normally by postoperative day 12 (0.46±0.08 g, N=6). In MKP-3 KO mice, this hypersensitivity persisted at least 12 days after surgery (0.19±0.06 g; N=6). KO mice displayed higher numbers of infiltrating cells (51.4±6 cells/0.1 mm2) than WT mice (8.7±1.2 cells/0.1 mm2) on postoperative day 1 (vs 5–6 cells/0.1 mm2 at baseline) that returned to baseline 12 days after surgery (10–12 cells/0.1 mm2). In WT mice, peripheral p-p38 and p-ERK-1/2 expression increased (5- and 3-fold, respectively) on postoperative days 1 and 5, and returned to basal levels 7–12 days after surgery (N=3 per group). Peripheral p-p38 levels in MKP-3 KO mice followed a similar expression pattern as WT mice. Peripheral p-ERK-1/2 levels in MKP-3 KO mice remained elevated 12 days after surgery (2.5-fold, N=3 per group). Administration of PD98059 (MEK inhibitor, N=8, vehicle N=9) reduced p-ERK-1/2 expression in the incised tissue and blocked hypersensitivity in MKP-3 KO mice (N=6). The findings of this study suggest that MKP-3 is pivotal for normal resolution of acute postoperative allodynia, through the regulation of peripheral p-ERK-1/2.

PD20-08 PREDICTORS OF PAIN RESOLUTION AFTER VARICOCELECTOMY FOR PAINFUL VARICOCELE

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Prostate & Genitalia I1 Apr 2016PD20-08 PREDICTORS OF PAIN RESOLUTION AFTER VARICOCELECTOMY FOR PAINFUL VARICOCELE Hyun Jun Park, Du Geon Moon, and Nam Cheol Park Hyun Jun ParkHyun Jun Park More articles by this author , Du Geon MoonDu Geon Moon More articles by this author , and Nam Cheol ParkNam Cheol Park More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1421AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES About 2-10% of men with varicocele complain of pain, mainly in the scrotum or inguinal area. Conservative management may be offered to these patients, including limitation of physical activities, scrotal elevation and treatment with non-steroidal anti-inflammatory analgesics. However, these often do not contribute to pain management. Although varicocelectomy can be a management option in these cases, various success rates and the lack of predictive parameters for surgical outcomes make it difficult for urologists treating patients with painful varicocele. We assessed the effectiveness of varicocelectomy for painful varicocele and examined the factors that might be predictive of outcome. METHODS All patients who underwent a varicocelectomy for pain were included. A review of patient medical records was conducted; patient age, body mass index (BMI), grade, location of the varicocele, testicular volume, duration and quality of the pain (dull, dragging, throbbing, or sharp), and surgical technique (inguinal vs. subinguinal) were documented. All parameters were compared with the resolution of pain (complete, partial, or failure). RESULTS We followed up on 53 of 104 patients (50.9%). Complete postoperative resolution of pain was reported by 28 patients (52.8%), whereas 22 (41.5%) reported partial resolution. Only three patients (5.7%) reported failure. No relationship was observed between postoperative pain resolution and age, BMI, grade of varicocele, location of varicocele, ipsilateral testicular hypotrophy, quality of pain, or surgical technique. The duration of pain before surgery was the only factor that correlated with postoperative pain resolution (univariate, P = 0.004; multivariate, P = 0.002). CONCLUSIONS Our results indicate that varicocelectomy is an effective treatment for painful varicocele in properly selected patients, and that duration of pain before surgery may be predictive of outcome. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e454 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Hyun Jun Park More articles by this author Du Geon Moon More articles by this author Nam Cheol Park More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Individual Differences in Acute Pain-induced Endogenous Analgesia Predict Time to Resolution of Postoperative Pain in the Rat

Chronic postsurgical pain, a significant public health problem, occurs in 10 to 50% of patients undergoing major surgery. Acute pain induces endogenous analgesia termed conditioned pain modulation (CPM), and the strength of CPM preoperatively predicts the likelihood of chronic postsurgical pain. The relation between CPM and recovery from surgery has not been examined in preclinical models. CPM was assessed in individual rats and correlated with each animal's time course of recovery of hypersensitivity after partial spinal nerve ligation. The role of descending noradrenergic pathways in the spinal cord to mechanisms of CPM and recovery was tested using idazoxan to block noradrenergic receptors or antidopamine β-hydroxylase-conjugated saporin to ablate these pathways. Behavioral hypersensitivity, static weight bearing, and spinal glial activation were measured after partial spinal nerve ligation. The strength of CPM varied over two-fold between individuals and was directly correlated with the slope of recovery from hypersensitivity after surgery (P < 0.0001; r = 0.660). CPM induced the release of norepinephrine in the spinal cord and was partially blocked by intrathecal idazoxan or dopamine β-hydroxylase-saporin. Dopamine β-hydroxylase-saporin also slowed recovery and enhanced spinal glial activation after partial spinal nerve ligation surgery. Ongoing activation of these pathways was critical to sustained recovery because intrathecal dopamine β-hydroxylase-saporin given 7 weeks after recovery reinstituted hypersensitivity, while having no effect in animals without previous surgery. Collectively, these studies provide a clear back-translation from clinical observations of CPM and chronic postsurgical pain and suggest that the ability to engage ongoing descending endogenous noradrenergic signaling may be critical in determining time course of recovery from hypersensitivity after surgery.

Douleurs chroniques après chirurgie : état des lieux

Any type of surgery can lead to persistent pain (Chronic Post-Surgical Pain, CPSP), including minor or less invasive procedures. CPSP often but not always includes neuropathic pain features; when a neuropathic component is present, CPSP is more severe. The major risk factors for the development of CPSP are well known but not selective. New tools to target high-risk patients preoperatively are currently being assessed (e.g. the risk index from Althaus and colleagues) but remains not specific enough. Today, the prevention of CPSP might be improved by a better management of the patients, specifically by a better control of severe acute postoperative pain (i.e. early diagnosis of a neuropathic component involved, judicious utilization of peri-operative opioid analgesics, use of pain trajectories to better assess postoperative pain resolution).

Spinal Mitogen-Activated Protein Kinase Phosphatase-3 (MKP-3) is Necessary for the Normal Resolution of Mechanical Allodynia in a Mouse Model of Acute Postoperative Pain

The mechanisms that drive the normal resolution of acute postoperative pain are not completely understood. We hypothesize a pivotal role of a major spinal mitogen-activated protein kinase (MAPKs) regulator, MAPK phosphatase (MKP)-3, in the resolution of postoperative pain. We used wild-type and MKP-3 knock-out (KO) mice, a paw incision model of acute postoperative pain, and behavioral and molecular biology experiments. We observed persistent mechanical allodynia in mice lacking MKP-3 (postoperative day 21), concurrently with persistent phosphorylation of spinal p38 and extracellular signal-regulated kinases (ERK)-1/2 on postoperative day 12, while both MAPK phosphorylation and allodynia resolved on postoperative day 7 in wild-type mice. Spinal p-ERK was expressed mainly in neurons and microglia, while spinal p-p38 was expressed mostly in microglia in MKP-3 KO mice, and their selective pharmacological inhibition reduced the persistent allodynia observed in these mice. Our findings strongly suggest that dysregulation of MKP-3 prevents spontaneous resolution of acute postoperative pain and drives its transition to persistent pain via persistent neuronal and microglial MAPK phosphorylation in the spinal cord.

Laparoscopic cholecystectomy for biliary dyskinesia: Which patients have long term benefit?

Biliary dyskinesia (BD) is described as biliary colic in the absence of gallstones. The diagnosis relies on imaging studies and decreased excretion of bile in response to cholecystokinin during quantitative cholescintigraphy. The purpose of this study was to evaluate the success of laparoscopic cholecystectomy (LC) for relieving symptoms in patients diagnosed with BD and correlate gallbladder ejection fraction (EF) with symptom relief. A retrospective review was performed at a single institution of all patients who underwent LC for BD from January 2005 through January 2012. The diagnosis of BD was determined by a normal gallbladder as viewed with ultrasonography and cholescintigraphy with a gallbladder EF less than or equal to 45%. Data collection included demographics, results of imaging studies, pathologic diagnosis, and early postoperative pain relief. Patients were contacted by phone after being discharged from the surgeon's care for evaluation of symptom relief. Data were analyzed with nonparametric statistical methods, including Mann-Whitney U test, receiver operator characteristic, Fisher exact test, and χ(2) test. All data are expressed as median and 25th and 75th percentile range. There were 126 patients who had a LC for BD during the study period. The median biliary EF was 20% (10-29%). The most common pathologic finding was chronic cholecystitis (n = 95; 75%). Median length of follow-up in the perioperative period was 11 days (8-17), during which time 98 patients (78%) had relief of symptoms. Phone interviews (n = 53; 42%) confirmed 66% (n = 35) of patients remained free of pain. There was no difference in the mean EF among those with resolution of pain 20% (10-29%) compared with patients with persistent pain 23% (11-29%), P = .62. Obese patients were more likely to have persistent symptoms in the perioperative period with a shift to lower body mass index at the time of the phone survey. Receiver operator characteristic characteristic for the association between scintigraphic EF and resolution of postoperative pain demonstrated no association, with the area under the curve equal to 0.47. The majority of patients in this series with BD had resolution of symptoms with LC. However, cholescintigraphy EF did not correlate with outcome. Further studies are needed to better identify patients diagnosed with BD who will benefit from LC.

Gene expression in skin, muscle, and dorsal root ganglion after plantar incision in the rat.

Treating postoperative pain remains a significant challenge for perioperative medicine. Recent studies have shown that nerve growth factor is up-regulated and contributes to incisional pain. To date, few studies have examined expression of other neurotrophin-related mediators that may contribute to the development and/or maintenance of incisional pain. Male Sprague-Dawley rats underwent a plantar incision, and pain behaviors were examined (n = 6). In a separate group of rats, expression of neurotrophic factors were studied. At various times after incision (n = 4) or sham surgery (n = 4), the skin, muscle, and dorsal root ganglia were harvested and total RNA isolated. Real-time reverse transcription polymerase chain reaction was performed and the fold change in gene expression was analyzed using significance analysis of microarrays. Several genes were changed (P < 0.05) as early as 1 h after incision. Expression of artemin and nerve growth factor were increased in both incised skin and muscle. Brain-derived neurotrophic factor, neurotrophin-3, and neurotrophin-5 were all down-regulated in the skin but up-regulated in the muscle 48 h after incision. Few genes changed in the dorsal root ganglion. Most changes in expression occurred in the first 48 h after incision, a timeframe when pain behavior was the greatest. Surgical incision is associated with pain-related gene expression changes in skin, muscle, and, to a lesser extent, dorsal root ganglion. The gene expression profile provides clues as to mediators that are involved in peripheral sensitization and pain transmission after surgical incision and also suggest mechanisms for resolution of postoperative pain when more persistent pain syndromes like neuropathic pain continue.

Postoperative Pain after Manual and Mechanical Glide Path: A Randomized Clinical Trial

Introduction This prospective randomized clinical trial evaluated the incidence of postoperative pain after glide path performed with PathFile (PF) (Dentsply Maillefer, Ballaigues, Switzerland) versus stainless-steel K-file (KF). Methods In 149 subjects, the mechanical glide path was performed with nickel-titanium (NiTi) rotary PF; in 146 subjects, the manual glide path was performed with stainless-steel KFs. Postoperative pain, analgesics consumption, and the number of days to complete pain resolution were evaluated in the following 7 days. An analysis of variance model for repeated measures was used to compare the variation of pain-scale values ( P < .05). The Student's t test for continuous variables normally distributed, the nonparametric Mann-Whitney U test for the nonnormally distributed variables, and the chi-square test for dichotomous variables were used ( P < .05). Despite homogeneous baseline conditions at diagnosis, tooth type, pain prevalence, and scores, the postoperative pain prevalence curves in PF group evidenced a more favorable trend in terms of time to pain resolution compared with the KF group ( P = .004). The difference was also evident in the model adjusted for analgesics consumption in both groups ( P = .012). The mean analgesics intake per subject was significantly higher in the KF group (3.7 ± 2.2) compared with the PF group (2 ± 1.7) ( P < .001). Mean pain stop values were also significantly higher in the KF group (2.7) compared with the PF group (1.7) ( P = .001). Conclusions The glide path with NiTi Rotary PF leads to less postoperative pain and faster symptom resolution.