Postprocedural Pain Research Articles

Comparison of Morbidity Associated with the use of Large Versus Small-Bore Chest Tubes in Patients Managed for Stage-I Empyema Thoracis

Objective: To compare pain and other complications with the use of large versus small-bore chest tubes in patients managed for Stage-I empyema thoracis.
 Study Design: Cross-sectional study.
 Place and Duration of Study: Combined Military Hospital, Multan Pakistan, from Jan 2015 to Jan 2022.
 Methodology: The study was conducted at the Trauma and Surgery Department. Files and charts of patients who were managed for Stage-I empyema thoracic in our hospital during the study period were assessed in detail. Patients were divided into two groups based on the size of the chest tube inserted to manage empyema thoracic. The presence of post-operative pain, obstruction, dislodgment and tube site infection were compared in both groups.
 Results: Out of 90 patients of Stage-I empyema thoracic, 43(47.8%) were inserted in small-bore chest tubes, while 47(52.2%) were inserted in large-bore chest tubes. Post-procedural pain was found significantly more in patients inserted in large chest tubes than those inserted in small bore tubes (p-value-0.018). All other complications did not differ statistically significantly in both groups.
 Conclusion: Most patients in both groups did not show significant complications after the chest tube insertion. Small chest tubes were better in terms of less post-procedural pain than large chest tubes, but other complications were not significantly different in both groups.Key words: Chest tube, Empyema, Pain, Thoracis.

Finding the optimal anesthetic technique during PCNL for renal stone disease: A comparison of general, spinal, and combined spinal epidural anesthesia

Background: Renal stone disease is prevalent worldwide. Percutaneous nephrolithotomy (PCNL) has become an important mode of treatment for large size renal stones. Various anesthetic techniques have described for performing PCNL, with each having its own merits and demerits. There is lacuna in evidence for the ideal mode of anesthesia with best results and least associated complications. Aims and Objectives: PCNL is a common procedure for renal stones. It can be performed under various anesthesia techniques. Selection of an appropriate anesthetic technique is essential for successful outcome. In this study, we compared three anesthesia techniques during PCNL and their outcomes. Materials and Methods: Retrospective and observational study involved all cases of PCNL performed from February 2022 to January 2023. Baseline clinical and anesthesia parameters were recorded. Three groups based on anesthesia method were made; Group A for general anesthesia (GA), B for spinal anesthesia (SA), and C for combined spinal epidural anesthesia (CSEA). Intraoperative variables including heart rate (HR), blood pressure, operation time, and analgesia adequacy were noted. Post-operative pain level, hospital stay, stone free rate (SFR), complications, patient, and surgeon satisfaction were recorded. Results: Seventy-two cases (56 Male and 16 Female) with a mean age of 36.2±15.9 years were included in the study. Age and body mass index were lower in Group A, while ASA status and comorbidities were comparable. Intraoperative HR and mean blood pressure were higher in Group A than in B and C (P=0.000, P=0.003). Hypotension was more frequent in Group B (24.1%, P=0.046). Operation time, hospital stay, transfusion rates, SFR, and overall patient satisfaction were similar. Group A patients experienced more post-procedure pain (Visual analogue scale 4.1 vs. 2.2 vs. 2.1; P=0.001). Nausea-vomiting and shivering episodes were also higher in Group A (P=0.033, P=0.021). Anesthetic effect weaned-off in 6 patients of SA. Post-operative headache was higher but non-significant in Group B and C (P=0.621). Conclusion: CSEA appears a superior alternative to both SA and GA, with additional adequate post-operative comfort.

Immuno-embolization plus PD1 antibody in metastatic uveal melanoma.

e21592 Background: More than 90% of patients with metastatic uveal melanoma (MUM) have metastatic disease in the liver. MUM has a poor prognosis following development of liver metastasis. Control of disease progression in the liver correlates with improved survival in MUM. We present a single-institution experience of treating MUM patients with immuno-embolization (IE) of liver metastasis using GM-CSF in combination with an anti-PD1 antibody (Pembrolizumab). Methods: This retrospective study includes MUM patients who received liver-directed therapy (IE) in combination with IV Pembrolizumab at the University of Iowa. Patients selected for IE treatment had liver-predominant metastatic disease involving less than 50% of the total liver parenchyma, total bilirubin < 2, serum albumin > 3, and patient ECOG PS of 0-1. Alternating lobar IE was administered every 4 weeks using a combination of GM-CSF (2000 mcg) and Lipiodol. Pembrolizumab was administered IV at 200 mg every 3 weeks. Results: 11 MUM patients received a total of 58 IE treatments concurrently with IV Pembrolizumab. 4 patients achieved stable disease, and 2 patients achieved partial response as their best radiographic response during treatment. 6 patients received additional lines of therapy; of these, 4 were enrolled into clinical trials. 5 patients were alive at the time of analysis, and 2 patients were actively receiving IE plus Pembrolizumab therapy. The median overall survival (OS) from diagnosis was 25.6 months, and the median OS from the first IE treatment was 21.3 months. Complications related to IE treatments included bleeding (n = 1), severe post-procedural pain (n = 2), infection (n = 1), and anaphylactic reaction (n = 1). No unexpected immune-related side effects occurred with Pembrolizumab. Specifically, no immune-related hepatic toxicity was reported in any patient. Conclusions: Immuno-embolization of liver metastasis using GM-CSF in combination with systemic check-point inhibitor therapy is promising in the treatment of MUM patients, and had no reported immunologic hepatic toxicity in a single-institution patient cohort. The treatment combination is currently being evaluated in a prospective clinical trial (NCT03472586).

Incidence of Chronic Pain following Oral Soft Tissue Biopsies: A Retrospective Study

Soft tissue oral biopsies (STOB) are commonly performed in the medical field to obtain tissue samples for diagnostic purposes. However, like all invasive procedures, these biopsies may carry risks, such as the development of chronic long-lasting neuropathic pain. This study aims to examine the occurrence of chronic pain following STOBs. A retrospective study was conducted on the medical records of 695 patients who underwent STOBs at the Maxillofacial Surgery Department of Hadassah Medical Center between the years 2013 and 2022. Demographic information, details of the procedure, histopathological diagnosis, and data related to post-procedure pain in the biopsy area were collected and analyzed. Out of the 695 patients, only 4 reports of chronic pain with mild intensity lasting more than three months following oral biopsy were documented, with incidence rate of 0.57%; all were females with a median age of 59 ± 2.0 years. The biopsies were taken from various sites and the common diagnoses were lichen planus, venous malformation, and fibromas. In conclusion, chronic pain after oral soft-tissue biopsies is rare, generally mild, and typically does not require extra therapy. These insights can aid clinicians and patients in making informed decisions about these procedures.

The Effect of Video Streaming With Virtual Reality on Anxiety and Pain During Bone Marrow Aspiration and Biopsy Procedure

BackgroundPain and anxiety are among the most common symptoms in patients undergoing invasive procedures. Increased pain levels tend to worsen anxiety, and anxiety often leads to more frequent or severe pain. AimsThe study was conducted to determine the efficacy of virtual reality goggles (VRG) on pain and anxiety during bone marrow aspiration and biopsy (BMAB) procedure. DesignA randomized controlled experimental study. SettingsThe outpatient unit of an adult hematology clinic of a tertiary care university hospital. Participants/SubjectsThe study was conducted in patients aged 18 years and older who underwent a BMAB procedure. Thirty-five patients in the experimental (VRG) group and 40 patients in the control group. MethodsPatient identification form, visual analogue scale (VAS), state and trait anxiety inventory (STAI), and VRG were used to collect the data. ResultsPostprocedural state anxiety mean scores were found to be statistically significantly higher in the control group than in the VRG group (p = .022). A statistically significant difference was found between groups in terms of procedure-related pain (p = .002). The postprocedural mean pain scores were found to be statistically significantly higher in the control group than in the VRG group (p < .001). A statistically significant but moderate positive correlation was found between the postprocedural pain and preprocedural state anxiety variable (r = 0.477). A statistically significant and strong positive correlation was found between the postprocedural pain and the postprocedural state anxiety variable (r = 0.657). A statistically significant but moderate positive relationship was found between preprocedural and postprocedural state anxiety variables (r = 0.519). ConclusionsWe determined that video streaming with VRG reduces pain and anxiety felt by adult patients during the BMAB procedure. VRG can be recommended to use in controlling pain and anxiety in patients undergoing a BMAB procedure.

(287) Office-Based Epididymectomy and Spermatocelectomy Under Local Anesthesia – An Excellent Option to Avoid General Anesthesia and Increase Access to Timely Care

Abstract Introduction Epididymectomy is indicated for patients with focal epididymal pain and bothersome epididymal cysts or masses. Similarly, spermatocelectomy is indicated for spermatoceles that have becomes symptomatic due to size or pain. The majority of scrotal surgeries are performed in the operating room (OR) using general or monitored anesthesia. Here, we sought to evaluate our experience with office-based epididymectomy and spermatocelectomy using only local anesthesia. Objective To evaluate post-procedural complications and pain resolution following epididymectomy or spermatocelectomy, comparing procedures performed in the clinic with only local anesthesia, compared to the OR. Methods We identified patients who underwent epididymectomy or spermatocelectomy at our institution from 2018-2021. A chart review was performed to identify pertinent information including whether the procedure was performed in the OR under monitored/general anesthesia versus in the clinic using only local anesthesia. Post-procedural outcomes including pain resolution (if applicable) and 30-day complications were compared between those who underwent epididymectomy or spermatocelectomy in the OR versus the office. Statistical analysis was performed using the chi-squared test. Results A total of 112 patients were identified, including 23 (20.5%) who underwent epididymectomy and 89 (79.5%) who underwent spermatocelectomy. Mean patient follow-up was 14.8 months (SD 11.6). Indications for epididymectomy or spermatocelectomy included pain (n= 50, 44.6%), epididymal cyst/mass (n=6, 5.4%), and mass effect secondary to spermatocele (n=56, 50.0%). Fifty-seven procedures (50.9%) were performed in the office under local anesthesia. Nitrous oxide was used in 21 (36.8%) of these cases. Thirty-four patients (30.3%) were on anticoagulation/antiplatelet therapy prior to surgery including 22 (64.7%) who continued anticoagulation/antiplatelet therapy due to high-risk comorbidities. The adverse event rate within 30 days was similar between patients who underwent surgery in clinic versus OR (p=0.67). Specifically, adverse events occurred in 9 patients (8.0%), of whom 4 had their procedure performed in the clinic (7.0% of clinic procedures) and 5 had their procedure performed in the OR (9.1% of OR procedures). Specific adverse events included postoperative hematoma in 6 patients (66%) and a single case of each of the following: infection, inability to void postoperatively, and intestinal obstruction. Hematoma rates did not differ significantly between those who were or were not on anticoagulation perioperatively (p=0.057). In patients with reported adverse events, 3 (33.3%) required reoperation. Of the 50 patients who underwent epididymectomy or spermatocelectomy for scrotal content pain, 39 had sufficient documentation available to evaluate pain resolution. 82% (n=32) reported 50% improvement in pain. There was no statistically significant difference in the likelihood of reporting significant pain reduction based on the location of the procedure (OR versus clinic). Conclusions Epididymectomy and spermatocelectomy can be successfully carried out in the office using only local anesthesia, including in those patients who are high risk for general anesthesia or require maintenance of anticoagulation perioperatively. Pain improvement may be anticipated in the majority of appropriately selected patients following treatment in either the clinic or OR. Disclosure No

Postprocedural Opioid-Prescribing Practice in Nail Surgery.

Ingrown toenails are a common condition requiring outpatient procedures in podiatric medical clinics. To prevent recurrence, chemical matrixectomy is often recommended. Postprocedural pain management is largely based on preferences rather than on a formal guideline. This study aims to explore the postprocedural prescribing behavior among practicing podiatric physicians to foster future guideline and policy development. We administered an open, voluntary, anonymous questionnaire via an online survey platform that included a common nail procedure scenario (chemical matrixectomy) and a prescribed demographics section. Podiatric physicians were asked what they would prescribe to manage postprocedural pain. Opioid and nonopioid options were provided. We developed two multiple logistic regression models to identify associations between prescriber characteristics and prescribing opioids after "standard" chemical matrixectomy. Of the 860 podiatrists who completed the survey, 8.7% opted to prescribe an opioid. Hydrocodone was most commonly chosen. A median of 18 opioid pills were prescribed. No prescriber characteristics were associated with prescribing opioids after chemical matrixectomy scenario. There is a large discrepancy and knowledge gap in the literature on the optimal postprocedural pain management for outpatient procedures, including procedures in specialties such as dentistry and dermatology. The median number of opioids prescribed by podiatrists is higher than that by dentists for management of third molar extraction. In contrast, opioid-prescribing behavior among the 8.7% of respondents is similar to dermatologic management of postprocedural pain in Mohs surgery. Podiatric physicians cannot assume that their prescribing of opioids does not affect the opioid abuse problem in the United States. The presented study serves to be an initiation for procedure-specific opioid prescription benchmarking to foster future guideline and policy development. After nail procedures, opioids should not be routinely prescribed.

PO-02-106 GENERAL ANESTHESIA VERSUS CONSCIOUS SEDATION WITH LOCOREGIONAL ANESTHESIA IN S-ICD IMPLANTATION: A MONOCENTRIC RETROSPECTIVE ANALYSIS

In patients not requiring pacing, the subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as a safe and effective alternative to the transvenous implantable cardioverter-defibrillator (TV-ICD) for the treatment of life-threatening ventricular arrhythmias. The S-ICD’s larger size requires a larger pocket for insertion and peri-procedural lead tunnelling carries high nociceptive potential, resulting historically in 65% of S-ICD implantations being performed under general anesthesia (GA). This study seeks to demonstrate that conscious sedation with locoregional anesthesia (CS-LA) is a safe and effective alternative to general anesthesia (GA) in S-ICD implantation. A total of 138 S-ICD implantations (90 under CS-LA) at our institution between 2013 and 2020 were studied The CS-LA technique was performed with conscious sedation, local anesthesia of the pocket and xyphoid incision sites, and post-procedural intercostal nerve blocade of the 4th to 7th intercostal spaces with a mixture of 10mL of 0.5% bupivacaine and 20mL of 2% lidocaine without epinephrine. Analgesic efficacy in the 24 post-operative hours was evaluated by Numerical Pain Rating Scale (NPRS) score and by total analgesic medication dosage received. Safety was evaluated by comparing the incidence of significant adverse events (AE): hypotension <80 mmHg or requiring vasopressors, bradycardia <40 bpm, or desaturation <90% for more than two minutes or requiring non-invasive ventilation maneuvers. Post-procedural pain at 15 minutes and at 24 hours was significantly less in the CS-LA group, with a difference of -0.90 (p=0.04) and -1.21 (p=0.004) respectively. Post-procedural opioid consumption was 10.64mg of per os morphine equivalents (p=0.046) lower than in the CS-LA group. No significant difference in the likelihood of at least one adverse event occurring was noted, with CS-LA demonstrating OR 1.95 (95% CI [0.86, 4.40], p=0.11) for at least one AE. Only one patient in the CS-LA arm required conversion to GA, due to excessive agitation during the procedure. S-ICD implantation under CS-LA was superior at 15 minutes and 24 hours to GA in terms of analgesic efficacy and post-procedural patient comfort. CS-LA’s safety profile was similar to GA, with no significantly increased risk of suffering at least one adverse event.

Importance of preemptive analgesia and pain assessment as perceived by intensive care unit nurses.

The importance and efficacy of Preemptive analgesia in reducing pain for patients undergoing painful procedures still debatable and seldom investigated. The aim of this study was to describe intensive care nurses' perception of the importance of pain assessment and Preemptive analgesia prior painful procedures in critical care settings in Jordan. A cross-sectional descriptive design was used. The sample consisted of 300 registered nurses recruited from 22 intensive care units in Jordan. The data was gathered using a self-administered questionnaire. The results showed that nurses considered pain assessment moderately and extremely important for surgical (n = 263, 87.7%), burn (n = 261, 87%), and trauma patients (n = 256, 85.3%). The majority of nurses rated pain assessment as moderately to extremely important for invasive line placement 80.3%, wound care 78.3%, and drain removal 69%. Nurses assessed the need for Preemptive analgesia more frequently before wound care 70.7%, and before invasive line placement 69.7%. Nurses perceived pain assessment for Preemptive analgesia as less priority for unconscious patients. Effective assessment and management of pain for critically ill patients is mandatory. Thus, it is important to improve nurses' knowledge regarding the Preemptive analgesia and its effects in relieving post-procedural pain in critically ill patient. It is recommended to ensure proper clinical training on how to assess critically ill patients and auditing system.

MP76-18 SELF-ADMINISTERED NITROUS OXIDE (SANO) DURING TRANSRECTAL PROSTATE BIOPSY TO REDUCE PATIENT PAIN AND ANXIETY: A DOUBLE-BLIND PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

You have accessJournal of UrologyCME1 Apr 2023MP76-18 SELF-ADMINISTERED NITROUS OXIDE (SANO) DURING TRANSRECTAL PROSTATE BIOPSY TO REDUCE PATIENT PAIN AND ANXIETY: A DOUBLE-BLIND PROSPECTIVE RANDOMIZED CONTROLLED TRIAL Suprita Krishna, Alejandro Abello, Abigail Escobar, Heidi Rayala, Chris Mistretta, Aria Olumi, Boris Gershman, Ruslan Korets, Peter Chang, and Andrew Wagner Suprita KrishnaSuprita Krishna More articles by this author , Alejandro AbelloAlejandro Abello More articles by this author , Abigail EscobarAbigail Escobar More articles by this author , Heidi RayalaHeidi Rayala More articles by this author , Chris MistrettaChris Mistretta More articles by this author , Aria OlumiAria Olumi More articles by this author , Boris GershmanBoris Gershman More articles by this author , Ruslan KoretsRuslan Korets More articles by this author , Peter ChangPeter Chang More articles by this author , and Andrew WagnerAndrew Wagner More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003350.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Commonly used in Europe, inhaled nitrous oxide (N2O) is gaining traction in the US as a method to decrease peri-procedural anxiety and pain. At concentrations <50%, N2O is classified as minimal sedation, making it a promising option for many urologic outpatient procedures such as prostate biopsy. The aim of our study was to determine whether self-administered nitrous oxide (SANO) decreases perception of anxiety and pain in patients undergoing transrectal prostate-needle biopsy (TRUS-Bx) and to evaluate its safety profile in the ambulatory setting. METHODS: This is a single-center prospective randomized double-blind controlled trial comparing SANO versus oxygen placebo in patients undergoing TRUS-Bx. Pre- and post-procedural pain and anxiety levels were measured using the Visual Analog Scale for pain (VAS-P) and Anxiety (VAS-A). Univariate logistic regression model was used to estimate odds ratio for pain and anxiety dichotomized as VAS 0 vs VAS>0 and group assignment. Our secondary outcomes included operator ease which was measured by surveying the blinded Urologist, complications and duration of procedure. RESULTS: 128 patients were randomized to SANO or oxygen placebo. Patients in the SANO group had a smaller change in post-biopsy pain score (VAS-P 0.43 vs 1.03; p=0.03), and patients had lower odds of experiencing pain during the procedure (OR: 0.45 (0.21-0.97); p=0.04). Patients in the SANO group also had a lower anxiety scores evidenced by a larger decrease in post-biopsy anxiety levels (VAS-A score 1.23 vs 0.61; p=0.09), though this did not reach statistical significance. Based on the blinded operator survey, patients randomized to the SANO group tolerated the procedure “better than expected” (61% vs 41%; p=0.02). Procedure time did not differ significantly between groups. There were no significant complications in either group. CONCLUSIONS: Patients receiving SANO during transrectal prostate biopsy had significantly lower pain levels and trended towards lower anxiety levels. Blinded Urologists perceived patients in the SANO group tolerated the procedure significantly better than the oxygen group. These encouraging results support the use of SANO to improve patient experience of care during prostate biopsies and may be a particularly promising option for patients with a history of anxiety or apprehension surrounding invasive procedures. Source of Funding: Disposables (mask) provided by Nitrouseal © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1099 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Suprita Krishna More articles by this author Alejandro Abello More articles by this author Abigail Escobar More articles by this author Heidi Rayala More articles by this author Chris Mistretta More articles by this author Aria Olumi More articles by this author Boris Gershman More articles by this author Ruslan Korets More articles by this author Peter Chang More articles by this author Andrew Wagner More articles by this author Expand All Advertisement PDF downloadLoading ...

Clinical outcomes following mechanochemical ablation of superficial venous incompetence compared with endothermal ablation: meta-analysis.

Mechanochemical ablation (MOCA) is an alternative method to endovenous thermal ablation (EVTA) for the treatment of superficial venous incompetence that does not require tumescent anaesthesia. The aim of this study was to compare the outcomes from RCTs of MOCA versus EVTA. A search was conducted in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL). Meta-analysis inclusion was restricted to RCTs comparing MOCA against EVTA. Outcomes included anatomical occlusion rate, disease-specific quality of life using the Aberdeen Varicose Vein Questionnaire, procedural and postprocedural pain, and rates of venous thromboembolism. Four RCTs were included in the meta-analysis comprising 654 patients. The anatomical occlusion rate at 1 year was lower after MOCA than EVTA (risk ratio 0.85, 95 per cent c.i. 0.78 to 0.91; P < 0.001). No significant differences were detected in procedural pain (mean difference -3.25, -14.25 to 7.74; P = 0.560) or postprocedural pain (mean difference -0.63, -2.15 to 0.89; P = 0.420). There were no significant differences in Aberdeen Varicose Vein Questionnaire score at 1 year (mean difference 0.06, -0.50 to 0.62; P = 0.830) or in incidence of venous thromboembolism (risk ratio 0.72, 95 per cent c.i. 0.14 to 3.61; P = 0.690). The rate of successful anatomical occlusion after MOCA is significantly lower than that after EVTA, but there is no difference in procedural and postprocedural pain between the two interventions. Long-term data are required to assess the impact of the reduced vein occlusion rate on clinical outcomes such as quality of life and reintervention.

Local anaesthetic infiltration in rubber band ligation of rectal haemorrhoids: study protocol for a three-arm, double-blind randomised controlled trial (PLATIPUS trial)

IntroductionRubber band ligation (‘banding’) is a common approach for the management of symptomatic haemorrhoids. However, up to 90% of patients experience postprocedural pain, and there is no consensus regarding the...

Endoscopic therapy for Barrett’s esophagus: a narrative review of potential complications and their management

: Barrett’s esophagus (BE) is a well-known risk factor for the development of esophageal adenocarcinoma (EAC). This histologic transformation occurs in a stepwise fashion with progression from intestinal metaplasia (IM) to low-grade dysplasia (LGD), high-grade dysplasia (HGD), intramucosal adenocarcinoma (IMCA), and ultimately invasive EAC. Standardized guidelines have been developed for screening, surveillance and treatment of dysplastic/neoplastic BE. Endoscopic eradication therapy (EET) is recommended over esophagectomy for dysplasia and early (mucosal) neoplasia based on its efficacy and favorable risk profile. EET consists of endoscopic resection of any nodular lesions followed by endoscopic ablation of Barrett’s mucosa. Endoscopic resection can be performed by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). There are several effective modalities available for endoscopic ablation including radiofrequency ablation (RFA), cryoablation, argon plasma coagulation (APC), and/or hybrid-APC. Often times, multimodal endoscopic therapy is utilized with a combination of endoscopic resection and ablation techniques. While generally well tolerated, complications from these therapeutic procedures do occur, including sedation-related events, post-procedure chest pain, luminal perforation, bleeding and esophageal stricture. Complications may occur intraprocedure, immediately post-procedure, or delayed post-procedure. Treatment depends upon the severity of the complication, hemodynamic stability of the patient, and timing of presentation. This review highlights the potential complications associated with BE endotherapy and the management thereof.

Safety profile and technical success rate of computed tomography-guided atlanto-axial lateral articulation injections.

To describe the technique, safety profile, and outcome of computed tomography (CT)-guided atlanto-axial lateral articulation injections performed at our institution. Consecutive cases of all CT-guided atlanto-axial injections performed from January 2017 to April 2022 at our institution were searched in the electronic medical records. Patient charts were reviewed for demographics, characterization of pain, potential altered anatomy, pain level before and immediately after the procedure, procedure technique, complications, and follow-up outcomes, if available. Forty-five injections in 40 different patients were included. The average age was 67.4 years, and 28 (70%) of the patients were female. Of the 45 injections, 43 (96%) were technically successful. The average change in pain score (0-10) from immediately before to immediately after the injection was -3.36 (SD = 2.87, range = -8 to +3). Of all injections, 14 (31%) had a postprocedural pain score of zero. In 2 cases (4%), patients reported an increase in pain score immediately after the injection. In 3 cases (7%), transient non-vertebral artery vascular uptake of contrast was documented during the procedure, which could be cleared with needle repositioning. There were no complications. CT-guided atlanto-axial lateral articulation injection is a safe procedure with a high technical success rate. It allows for direct visualization of vital structures and provides an alternative option to the traditional fluoroscopic guidance, especially in cases of prior technically unsuccessful fluoroscopically guided injection or altered anatomy.

ELEVATIONS IN END TIDAL CO2 WITH CO2 USE DURING PEDIATRIC ENDOSCOPY WITH AIRWAY PROTECTION: IS THIS PHYSIOLOGICALLY SIGNIFICANT?

Inflation of the gastrointestinal lumen is vital for proper visualization during endoscopy. Air, insufflated via the endoscope, is gradually being replaced with carbon dioxide (CO2) in many centers, with the intention of minimizing post-procedural discomfort due to retained gas. Recent studies suggest that the use of CO2 during pediatric esophagogastroduodenoscopy (EGD) with an unprotected airway is associated with transient elevations in exhaled CO2 (end-tidal CO2, EtCO2), raising safety concerns. One possible explanation for these events is eructation of insufflation gas from the stomach. To distinguish eructated vs absorbed CO2 by sampling EtCO2 from a protected airway with either laryngeal mask airway (LMA) or endotracheal tube (ETT), and to observe for changes in minute ventilation (MV) to exclude hypoventilation events. Double-blinded, randomized clinical trial of CO2 versus air insufflation for EGD with airway protection by either LMA or ETT. Tidal volume, respiratory rate, MV, and EtCO2 were automatically recorded every minute. Cohort demographics were described with descriptive characteristics. Variables including the percent of children with peak, transient EtCO2 ≥ 60mmHg were compared between groups. 195 patients were enrolled for 200 procedures. Transient elevations in EtCO2 of ≥ 60mmHg were more common in the CO2 group, compared to the air group (16% vs. 5%, p=0.02), but were mostly observed with LMA and less with ETT. Post-procedure pain was not different between groups, but flatulence was reported more with air insufflation. (p=0.004). Transient elevations in EtCO2 occur more often with CO2 than with air insufflation during pediatric EGD despite protecting the airway with an LMA or, to a lesser degree, with ETT. These elevations were not associated with changes in MV. Although no adverse clinical effects from CO2 absorption were observed, these findings suggest that caution should be exercised when considering the use of CO2 insufflation, especially since the observed benefits of using this gas were minimal.

Ultrasound-guided nerve block prior to biopsy of suspected neurogenic tumors: safety and feasibility in a pilot study.

The aim of this study is to investigate the safety and feasibility of ultrasound-guided nerve block prior to biopsy of potentially neurogenic tumors. A retrospective review of the medical record from June 2017 to June 2022 identified ultrasound-guided biopsies of potentially neurogenic tumors that were performed with a pre-procedural nerve block. Patient demographics, biopsy site, number of passes, needle gauge, use of sedation, pathology results, and procedural complications were recorded and summarized. The structured search found 16 patients that underwent biopsies of 18 potentially neurogenic tumors with the use of a pre-procedural nerve block at a variety of upper and lower extremity locations. Average patient age was 52 (range 18-78) and 9 patients (56%) were female. Of the 16 patients, 10 were performed without intravenous sedation. Three patients were unable to tolerate biopsy until a nerve block was used. All biopsies yielded a diagnostic sample with 13 of the tumors neurogenic in origin. One patient reported mild postprocedural pain which resolved with conservative treatment; no other complications were reported. Nerve block prior to ultrasound-guided biopsy of potentially neurogenic tumors is a safe and feasible technique. Further study is needed to determine the extent to which nerve block can decrease intra-procedural pain and reduce or eliminate the need for sedation during biopsy.

Protocols and Techniques for Orthobiologic Procedures.

Many procedural techniques have been described and used for orthobiologics procedures with little research on the ideal technique. This section outlines the commonly used materials and techniques from start to finish for these procedures. Post-procedure pain is common during and after many of these injections, and local and regional anesthesia during these procedures is discussed. Accuracy and safety of tendon, ligament, cartilage, intra-osseous, and spinal orthobiologic procedures are improved with the utilization of image guidance.

Peroral endoscopic myotomy: is it better to perform it in naive patients or as second-line therapy? Results of an open-label-controlled study in 105 patients

BackgroundWhether Peroral Endoscopic Myotomy (POEM) can be proposed as a second-line treatment in patients with achalasia remains to be confirmed in real-life series.ObjectiveThis study aimed to compare the efficacy, feasibility and safety of POEM between treatment-naïve patients and patients who had prior endoscopic or surgical therapies for achalasia.MethodsAll consecutive patients who underwent a POEM procedure for achalasia in our centre from June 2015 to September 2018 were included in this retrospective study. They were classified into treatment-naïve patients (POEM1) and patients who had at least one previous endoscopic and/or surgical treatment for achalasia (POEM2).ResultsA total of 105 patients were included, 52 in the POEM1 group and 53 in the POEM2 group. Clinical success (defined as an Eckardt score ≤ 3) at 6 months was observed in 93% of POEM1 patients and 84% of POEM2 patients (p = 0.18). Technical success rate was not significantly different between the two groups (100% vs 96%, respectively; p = 0.50). No significant difference was noted in terms of adverse event rate (19% vs 19%, respectively; p = 1.00). Post-procedure pain occurred in 12% of treatment-naive and 9% of non-naïve patients (p = 0.76). The median length of hospital stay was 3 days in both groups (p = 0.17). Symptomatic gastroesophageal reflux occurred in 25% of POEM1 patients and 16% of POEM2 patients (p = 0.24).ConclusionEfficacy, feasibility and safety of POEM are not different between treatment-naïve and non-naïve patients. POEM is a valuable second-line approach in patients with persistent symptoms of achalasia after surgical or endoscopic treatments.

THE RELATIONSHIP BETWEEN CYST DIAMETER AND LONG-TERM RESULTS OF PAIR TREATMENT

Aim: The PAIR (Puncture, Aspiration, Injection of scolicidal agent, and Reaspiration) treatment is used for echinococcosis type 1 (CE1) liver hydatid cysts. The aim of this study is to show the relationship between the cyst diameter and long-term results of PAIR. Materials and Methods: Between 2016-2021, fifthy patients with 54 liver CE1 hydatid cysts who underwent PAIR treatment were included in the study. Under general anesthesia, procedures were carried out. Technical success (completing the required steps in a procedure), clinical success (absence of recurrence or major complication upon follow-up), complications, cyst cavities' long-term alterations were evaluated. Inactivation times of cysts smaller than 6 cm and larger than 6 cm were compared. Results: The long axis of the cysts was between 3 cm and 12 cm. Technical success rate was 100%. The average follow-up time was 996 ± 250 days. The cysts showed a mean volume reduction of 70.1% on follow up. The treatment was effective in 48 patients and 52 hydatid cysts. The effectiveness of the long-term treatment was 96%. Cysts smaller than 6 cm had a significantly shorter inactivation time than cysts larger than 6 cm (p=0.01). Recurrence (CE2) was detected in one patient (2 %). This patient was treated with the modified catheterization (MoCAT) technique. Major complication (abscess) was detected in one patients (2 %) and abscess was drained using the percutaneous seldinger technique. Intra-abdominal spread, anaphylaxis, or mortality did not develop in any patient. Post-procedural pain developed in 3 patients as a minor complication (6 %). Conclusion: Although the inactivation time is longer in cysts larger than 6 cm, PAIR technique used to treat liver CE 1 hydatid cysts are effective and secure.

Diagnostic efficacy of endoscopic ultrasound-guided liver biopsy for diffuse liver diseases and its predictors - a multicentric retrospective analysis.

Endoscopic ultrasound (EUS)-guided liver biopsy (LB) has become an increasingly popular method of tissue acquisition for evaluating liver diseases. Despite its advantages, EUS-LB has not been widely adopted in clinical practice due to concerns regarding efficacy and safety. Present data on EUS-LB from India are scarce. We aimed to study the diagnostic outcome and safety of EUS-guided liver biopsy. This is a retrospective analysis of prospectively maintained data from January 2021 to October 2022 of consecutive patients undergoing EUS-LB at four tertiary care centers in India. The primary outcome was sample adequacy, while secondary outcomes were rate of successful pathological diagnoses and incidence of adverse events (AE). A total of 74 patients (median age: 44.5 years, 50.0% males) were included. The majority of the patients underwent left-lobe biopsy (62/74, 83.7%), and a 19-G Franseen FNB needle was most commonly used (61/74, 82.4%). Wet heparin suction was used in most cases (60/74, 81.1%). There were five mild AEs observed (one case of self-limited bleeding and four cases of post-procedural pain). Adequate and optimal samples were obtained in 71 (95.9%) and 49 (66.2%) cases, with a conclusive diagnosis being made in 97.3% (72/74) of the patients. On multivariate analysis, the presence of ascites was a negative predictor of optimal sample (odds ratio [OR] = 0.128, 95% CI: 0.017-0.96). EUS-LB is a safe and viable alternative to percutaneous liver biopsy, achieving diagnosis in > 95% of cases. EUS-LB can be performed safely even in patients with mild ascites, although ascites reduces the chances of getting an optimal sample.