Single-blind randomized clinical trial of laparoscopic versus open appendicectomy in children

BACKGROUND: Appendicectomy is the most common emergency surgical operation in children. The aim of this study was to compare recovery after appendicectomy using either a laparoscopic or an open technique in children. METHODS: Sixty-one children aged 4-15 years undergoing appendicectomy for suspected uncomplicated appendicitis were studied. The study was prospective, randomized and single-blinded, with parallel groups. Standardized anaesthetic technique and pain management were used. The study endpoints were postoperative pain, need for rescue analgesia, and length of hospital stay. RESULTS: Children had significantly less pain after laparoscopic compared with open appendicectomy 8 h after operation and on the first and second postoperative mornings (P < 0.05). Laparoscopic appendicectomy resulted in a reduced requirement for rescue analgesia with oxycodone in hospital: mean(s.d.) 3.6(2.5) versus 5.8(3.3) doses (mean difference 2.2 doses, 95 per cent confidence interval (c.i.) 0.6--3.8 doses); P = 0.01. The mean(s.d.) length of hospital stay was significantly shorter in the laparoscopic group: 1.9(0.7) versus 2.6(0.9) days (mean difference 0.7 days, 95 per cent c.i. 0.3--1.1 days); P = 0.001. Three children who had open appendicectomy developed a wound infection. CONCLUSION: Laparoscopic appendicectomy is associated with less postoperative pain and a shorter hospital stay than open appendicectomy in children undergoing surgery for uncomplicated appendicitis.     

A double-blind, randomized, active-controlled study for post-hemorrhoidectomy pain management with liposome bupivacaine, a novel local analgesic formulation

This randomized, active-controlled study evaluated the extent and duration of analgesia after administration of liposome bupivacaine (LB), a novel formulation of bupivacaine, compared with bupivacaine HCl given via local infiltration in excisional hemorrhoidectomy. One hundred patients were randomly assigned to receive a single dose of bupivacaine HCl 75 mg (0.25% with 1:200,000 epinephrine) or LB 66, 199, or 266 mg upon completion of hemorrhoidectomy. Postoperative pain intensity was assessed using a numeric rating scale at rest to calculate a cumulative pain score (area under the curve). Cumulative pain scores were significantly lower with LB at each study dose (P < 0.05) compared with bupivacaine HCl 72 hours after surgery. Post hoc analysis showed that mean total postoperative opioid consumption was statistically significantly lower for the LB 266-mg group compared with the bupivacaine HCl group during the 12- to 72-hour postoperative period (P = 0.019). Median time to first opioid use was 19 hours for LB 266 mg versus 8 hours for bupivacaine HCl (P = 0.005). Incidence of opioid-related adverse events was 4 per cent for LB 266 mg compared with 35 per cent for bupivacaine HCl (P = 0.007). Local infiltration with LB resulted in significantly reduced postsurgical pain compared with bupivacaine HCl in patients after hemorrhoidectomy surgery.     

Multimodal analgesia with gabapentin and local anesthetics prevents acute and chronic pain after breast surgery for cancer

We evaluated the effect of multimodal analgesia on acute and chronic pain after breast surgery for cancer. Fifty patients scheduled for breast cancer surgery were blindly randomized to receive gabapentin, eutectic mixture of local anesthetics cream, and ropivacaine in the wound or three placebos. Pain (visual analog scale) and analgesics were recorded in the postanesthesia care unit (PACU) 3, 6, and 9 h and 8 days after surgery. Three and 6 mo later, patients were assessed for chronic pain. The treatment group consumed less paracetamol in the PACU (469 versus 991 mg; P < 0.002) and less Lonalgal (1.0 versus 4.4 tablets; P = 0.003) than the controls, exhibited lower visual analog scale scores at rest in the PACU (P = 0.001) and on postoperative Days 1, 3, and 5 (P = 0.040, P = 0.015, and P = 0.045, respectively), and after movement in the PACU (P = 0.001) and on postoperative Days 2, 4, and 8 (P = 0.028, P = 0.007, and P = 0.032, respectively). Three and 6 mo after surgery, 18 of 22 (82%) and 12 of 21 (57%) of the controls reported chronic pain versus 10 of 22 (45%) and 6 of 20 (30%) in the treatment group (P = 0.028 and P = 0.424, respectively); 5 of 22 and 4 of 21 of the controls required analgesics versus 0 of 22 and 0 of 20 of those treated (P = 0.048 and P = 0.107, respectively). Multimodal analgesia reduced acute and chronic pain after breast surgery for cancer.     

A prospective, randomized trial of cognitive intervention for postoperative pain

A single-blind, randomized prospective trial was performed at a university hospital to determine if preoperative relaxation training will decrease pain and narcotic demand postoperatively. A convenience sample of 49 patients undergoing lumbar and cervical spine surgery was randomized to receive instruction on relaxation techniques or routine preoperative information before surgery. Pain score and narcotic demand in the first 48 hours after surgery were the primary outcomes. Pain scores were higher in the relaxation (4.8 +/- 1.7) versus the standard preparation group (3.9 +/- 1.7) on postoperative day one (POD) 1, but lower on POD 2 (3.9 +/- 1.9 vs 4.1 +/- 1.9), whereas narcotic use (milligrams of IV morphine per hour) was higher in the relaxation group on POD 1 (1.14 +/- 0.94 vs 0.54 +/- 0.55) and POD 2 (0.86 +/- 0.73 vs 0.50 +/- 0.61). The differences were significant for narcotic demand (P = 0.01) but not for pain (P = 0.94). In conclusion, our results could not support the use of relaxation training for reducing postoperative pain and narcotic demand in this selected surgical population.     

Questionnaires on patient-controlled analgesia to the nursing staff in the surgical ward]

Thirty-one nurses in the surgical ward engaged in delivering postoperative analgesia using patient-controlled analgesia (PCA) were asked to complete questionnaires on postoperative analgesia and PCA. Ninety-seven per cent of respondents agreed that the postoperative analgesia is beneficial for postoperative recovery, and answered that the desirable goal in postoperative analgesia is "no pain at rest". Not only "pain at movement" or "pain on coughing", but also "decreased conscious level while analgesia is achieved" were selected as undesirable conditions during postoperative course. Although no one had learned the concept of PCA in their nursing schools, 94 per cent of respondents approved PCA as a method for postoperative analgesia. Seventy seven per cent responded that PCA is effective in the pain relief during position change, pulmonary physiotherapy and induced early ambulation. In addition, 65 per cent of respondents chose PCA as a method for postoperative analgesia when they receive thoraco-abdominal surgery. On the other hand, some problems on pain management using PCA, such as taking care of patients' ambulation with carrying a PCA pump, extra time for instruction of PCA and extra support for patients' psychological state were listed. In conclusion, these results suggest that PCA is accepted as an excellent method for postoperative analgesia among our nurses in the surgical ward, and education in postoperative pain management including PCA is required in nursing school as well as after graduation.     

Randomized clinical trial of the influence of intraperitoneal local anaesthesia on pain after laparoscopic surgery

BACKGROUND: There is controversy about the effectiveness of intraperitoneal local anaesthesia (LA) in laparoscopic surgery. The aim of the present randomized clinical trial was to compare the analgesic effect of pre-emptive (preoperative) versus postoperative intraperitoneal LA in two different types of laparoscopic surgery. METHODS: Between July 2004 and January 2005, 133 consecutive patients scheduled to undergo laparoscopic fundoplication or hernia repair were randomly assigned to one of three treatments: placebo solution (50 ml 0.9 per cent saline) or LA (50 ml 0.5 per cent lidocaine) administered immediately after creation of the pneumoperitoneum, or LA (50 ml 0.5 per cent lidocaine) at the end of the operation. Analgesic requirements were analysed, and pain was assessed using a visual analogue scale (VAS) from 0 to 100 at 6, 12, 24 and 48 h after surgery. RESULTS: The duration of pneumoperitoneum (median 66 versus 46 min respectively; P < 0.001) and overall pain intensity (median VAS score 46.7 versus 6.5; P < 0.001) were higher for laparoscopic fundoplication than for hernia repair. Preoperative application of LA reduced abdominal pain (median 28.6 versus 74.9; P < 0.005), shoulder pain (median 24.3 versus 43.8; P = 0.004) and analgesic consumption (mean(s.d.) 11.1(5.0) versus 18.5(5.4) mg piritramide per 48 h; P = 0.002) after fundoplication, but had no analgesic effects after hernia repair. CONCLUSION: Pre-emptive application of LA reduced postoperative pain and analgesic requirements after laparoscopic fundoplication.     

Clinicopathological features and prognosis of gastric cancer in young European adults

BACKGROUND: The aims of this study were to define the clinicopathological features and prognosis of gastric cancer in young European adults. METHODS: Between 1990 and 2004, 603 patients with gastric cancer were enrolled in a prospective database. The findings for 51 (8.5 per cent) patients aged 45 years or less were compared with those of 457 aged between 46 and 75 years. RESULTS: In the younger group there were significantly more women (57 versus 36.3 per cent; P = 0.004), Laurén diffuse-type carcinomas (73 versus 42.7 per cent; P < 0.001), N2-3 lymph node metastases (59 versus 38.9 per cent; P = 0.005), stage IV disease (49 versus 35.7 per cent; P = 0.085) and resections that were non-curative (36 versus 18.5 per cent; P = 0.007) than in the older patients. Actuarial survival rates in younger patients at 5 and 10 years after resection were 40 and 32 per cent respectively, similar to those in older patients (P = 0.540). Unfavourable prognostic factors associated with poor 5-year survival were the degree of gastric wall invasion (T3-4 versus T1-2; P < 0.001), lymph node invasion (positive versus negative; P < 0.001), disease stage (III-IV versus I-II; P < 0.001) and curability of resection (non-curative versus curative; P < 0.001). CONCLUSION: Gastric cancer in young adults tends to be more advanced; however, when matched for stage, the prognosis does not differ from that of older patients.     

Posterior quadratus lumborum block versus epidural analgesia for postoperative pain management after open radical cystectomy: A randomized clinical trial

Background

In open abdominal surgery, continuous epidural analgesia is commonly used method for postoperative analgesia. However, ultrasound (US)-guided fascial plane blocks may be a reasonable alternative.

Methods

In this randomized controlled trial, we compared posterior quadratus lumborum block (QLB) with epidural analgesia for postoperative pain after open radical cystectomy (ORC). Adult patients aged 18–85 with bladder cancer (BC) scheduled for open RC were randomized in two groups. Exclusion criteria were complicated diabetes mellitus type I, lack of cooperation, and persistent pain for reasons other than BC. In one group, a bilateral US-guided single injection posterior QLB was performed with 3.75 mg/ml ropivacaine 20 ml/side. In the other group, continuous epidural analgesia with ropivacaine was used. Basic analgesia was oral paracetamol 1000 mg three times daily, and long-acting opioid twice daily in both groups. All patients had patient-controlled rescue analgesia with oxycodone. Postoperative cumulative rescue opioid consumption was recorded for the day of surgery, and the following 2 postoperative days (POD 0–2). Secondary outcomes were postoperative pain and nausea and vomiting.

Results

In total, 20 patients (QLB), and 19 patients (epidural analgesia) groups, were included in the analyses. Cumulative rescue opioid consumption on POD 0, being of duration 9–12 h, was 14 mg (7.6–33.3) in the QLB group versus 6.1 mg (2.0–16.1) in the epidural analgesia group, p = 0.089, and as doses, 8 doses (3.6–15.7) versus 4 doses (1.3–8.5), p = .057. On POD 1 consumption was 25.3 mg (11.0–52.9) versus 18.0 mg (14.4–43.7), p = .749, and as doses 12 (5.5–23.0) versus 10 (8–20), p > .9, respectively. On POD 2 consumption was 19.1 mg (7.9–31.0) versus 18.0 mg (5.4–27.6) p = .749, and as doses 8.5 (5.2–14.7) versus 11 (3.0–18.0) p > .9, respectively.

Conclusion

Opioid consumption did not differ significantly between posterior QLB and an epidural infusion with ropivacaine for the first 2 postoperative days following RC. Trial registration: ClinicalTrials.gov identifier NCT03328988.     

Interpleural analgesia improves pulmonary function after cholecystectomy

The purpose of this study was to examine the effects of interpleural bupivacaine on analgesia and ventilatory capacity after cholecystectomy. Forty-two patients undergoing elective cholecystectomy were randomly assigned to two groups: one to receive interpleural administration of bupivacaine-adrenaline mixture (Group 1 = 22 patients) and the other standard administration of intramuscular meperidine (Group 2 = 20 patients) for postoperative pain relief. The intensity of pain was evaluated by a visual analogue scale (VAS) preoperatively as well as at 2, 8, 24 and 48 hr postoperatively. At the same time, FVC and FEV1.0 measurements were obtained for all patients. The group given interpleural bupivacaine had better pain relief with mean VAS of 0.6 +/- 0.9 (mean +/- SD) 1.1 +/- 1.4, 0.6 +/- 0.9 and 0.8 +/- 1.2 compared with 5.2 +/- 2.2, 5.8 +/- 2.7, 5.5 +/- 2.2 and 4.5 +/- 1.8 for patients receiving meperidine (P less than 0.001). The patients in Group 1 also had larger FVC and FEV than those in Group 2: FVC 22 +/- 14.5 per cent vs 32 +/- 15.2 per cent (P less than 0.005), FEV1.0 25 +/- 15.5 vs 38 +/- 14.8 per cent (P less than 0.001) (mean +/- SD). We conclude that the interpleural analgesia can achieve better pain relief with greater ventilatory capacity than a standard analgesic regimen in the first two days after cholecystectomy.     

Randomized clinical trial of the effect of preoperative dexamethasone on nausea and vomiting after laparoscopic cholecystectomy

BACKGROUND: Preoperative dexamethasone may reduce disabling symptoms such as pain, nausea and vomiting after laparoscopic cholecystectomy. METHODS: This was a randomized, double-blind, placebo-controlled trial. Between March and December 2004, 101 patients undergoing laparoscopic cholecystectomy were randomized to receive 8 mg dexamethasone (n = 49) or placebo (n = 52) intravenously before surgery. Six patients were excluded from the study. All patients received a standardized anaesthetic, surgical and multimodal analgesic treatment. The primary endpoints were: first, postoperative nausea, vomiting and pain; second, postoperative analgesic and antiemetic requirements. The pain scores (visual analogue and verbal response scales), the episodes of nausea (verbal response scale) and vomiting were recorded at 1, 3, 6 and 24 h, respectively, after the operation. Analgesic and antiemetic requirements were also recorded. RESULTS: No apparent drug side-effects were noted. Seven patients (14 per cent) in the treatment group reported nausea and vomiting compared with 24 (46 per cent) in the control group (P = 0.001). In the group of patients treated with dexamethasone, five (10 per cent) required antiemetics versus 23 (44 per cent) of those receiving placebo (P < 0.001). No difference in postoperative pain scores and analgesic requirements was detected between groups. CONCLUSION: Preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy, with no side-effects, and may be recommended for routine use.     

Randomized clinical trial of Ligasure versus conventional diathermy for day-case haemorrhoidectomy

BACKGROUND: Haemorrhoidectomy is frequently associated with postoperative pain and prolonged hospital stay. A new technique of haemorrhoidectomy using the Ligasure device suited to day-case surgery is described. This technique was compared with conventional open diathermy haemorrhoidectomy. METHODS: Forty patients with grade III or IV haemorrhoids were randomized to Ligasure (group 1) or conventional diathermy (group 2) haemorrhoidectomy. Operative details were recorded and patients recorded daily pain scores on a linear analogue scale. Follow-up was at 1, 3, 6 and 12 weeks to evaluate complications, return to normal activity, ongoing symptoms and patient satisfaction. RESULTS: Reduced intraoperative blood loss (median (range) 0 (0-5) ml versus 20 (12-22) ml; P < 0.001) and a shorter operating time (10 (8-11) versus 20 (18-25) min; P < 0.001) was observed in group 1 compared with group 2. More patients in group 1 were discharged on the day of operation (18 of 20 versus 11 of 20; P < 0.05) and there was a trend towards lower postoperative pain scores on day 1 (group 1 median 5 (95 per cent confidence interval (c.i.) 2.6 to 6.8) versus group 2 7 (95 per cent c.i. 4.2 to 7.7); P = 0.36). There was no difference between the two groups in the degree of patient satisfaction or number of postoperative complications. CONCLUSION: Ligasure diathermy may be used safely in the treatment of patients with grade III or IV haemorrhoids. It reduces intraoperative blood loss and operating time, and facilitates same-day discharge.     

Randomized controlled trial to examine the influence of thoracic epidural analgesia on postoperative ileus after laparoscopic sigmoid resection.

BACKGROUND: The aim of the study was to evaluate whether perioperative epidural analgesia had any effect on the duration of postoperative ileus after laparoscopic sigmoid resection. METHODS: Twenty patients were randomized to surgery either with (group 1; n = 10) or without (group 2; n = 10) thoracic epidural analgesia. The major endpoint of the study was the time to the first postoperative bowel movement. Secondary endpoints were the interval until oral feeding was tolerated, incidence of postoperative vomiting, postoperative analgesic consumption use of patient-controlled analgesia (PCA) until the fourth day after operation, subjective pain perception and the incidence of epidural-related side-effects. RESULTS: Age, sex and American Society of Anesthesiologists classification were similar in the two groups. The first bowel movement was documented after a median of 54 (95 per cent confidence interval 32-127) h in group 1 and 77 (31-99) h in group 2 (P = 0.8). Oral feeding without additional parenteral therapy was tolerated after 48 (40-64) h in group 1 and after 56 (48-64) h in group 2 (P = 0.6). Postoperative vomiting occurred in two patients from each group. During epidural therapy the use of PCA was lower in group 1 (0.30 (0.19-0.96) mg morphine per kg) than in group 2 (0.56 (0.37-0. 80) mg/kg) (P < 0.05). Postoperative pain perception during rest and while coughing was similar in both groups. Three patients experienced reversible side-effects of epidural therapy (motor deficit, two patients; bladder dysfunction, one). CONCLUSION: Perioperative thoracic epidural analgesia did not have a clinically relevant effect on the duration of postoperative ileus after laparoscopic sigmoid resection.     

Does a preemptive block of the great auricular nerve improve postoperative analgesia in children undergoing tympanomastoid surgery?

We performed a double-blinded randomized controlled trial to evaluate the efficacy of preemptive analgesia in children undergoing tympanomastoid surgery. Children were divided into two groups: group block-block (BB) received a preemptive great auricular nerve block (GAN-block) with 0.25% bupivacaine with 1:200,000 epinephrine before incision followed by a second GAN-block with 0.25% bupivacaine with 1:200,000 epinephrine 1 h before the end of the procedure. Group sham block-block (SB-B) received a preemptive GAN-block with normal saline before surgical incision followed by a GAN-block with 0.25% bupivacaine with 1:200000 epinephrine 1 h before the completion of the procedure. All patients were evaluated for pain with the objective pain score (OPS) by a blinded observer. There was no difference in pain rescue requirements in the postanesthesia care unit (BB versus SB-B, 1 of 20 versus 3 of 20, P= 0.60) or in the short-stay unit (BB versus SB-B, 5 of 20 versus 11 of 20, P = 0.107) or for the entire hospital stay (P = 0.20). There was no significant difference between groups in the time to first rescue pain medication (BB versus SB-B, 226 +/- 71 min versus 201 +/- 94 min). There was no significant difference between groups regarding vomiting in the postoperative period (P = 0.52). We conclude that a preoperative GAN-block does not offer significant advantages for postoperative pain relief in children undergoing tympanomastoid surgery. IMPLICATIONS: This double-blinded randomized controlled trial compared the efficacy of preemptive analgesia with a peripheral nerve block of the great auricular nerve for decreasing postoperative pain in children undergoing tympanomastoid surgery. Preemptive analgesia did not improve the quality or duration of postoperative analgesia in our cohort.     

Randomized clinical trial of the effects on anal function of Milligan-Morgan versus Ferguson haemorrhoidectomy

BACKGROUND: Studies of haemorrhoidectomy usually report postoperative pain, healing and complications, but rarely consider anal function in the longer term. The primary aim of this randomized trial was to compare long-term changes in anal function after open (Milligan-Morgan) and closed (Ferguson) haemorrhoidectomy. METHODS: A total of 225 patients were included in the trial, 115 in the open group and 110 in the closed group. Continence changes were recorded by means of validated questions and an incontinence score. Pain was self-reported using a visual analogue scale. RESULTS: Postoperative pain and complications did not differ between the groups. Time to recovery was 17 days in the Milligan-Morgan group and 15 days in the Ferguson group. After 1 month the wounds were healed in 57.0 per cent of patients in the open group and 70.6 per cent of those in the closed group (P = 0.058). At 1 year, 78.9 per cent of the Milligan-Morgan group and 85.3 per cent of the Ferguson group reported no continence disturbance (P = 0.072). The incontinence score was improved at 1 year in the closed group (P = 0.015), but was unchanged in the open group (P = 0.645). Patients who had the Ferguson procedure were more satisfied with the outcome of surgery (P = 0.047). CONCLUSION: Closed Ferguson haemorrhoidectomy was superior to the open Milligan-Morgan procedure with respect to long-term anal continence and patient satisfaction.     

The effects of three different analgesia techniques on long-term postthoracotomy pain.

In this clinical, randomized, prospective study, we compared the effects of three different analgesia techniques (thoracic epidural analgesia [TEA] with and without preoperative initiation and IV patient-controlled analgesia [IV-PCA]) on postthoracotomy pain in 69 patients. In two groups, a thoracic epidural catheter was inserted preoperatively. Group Pre-TEA had bupivacaine and morphine solution preoperatively and intraoperatively. Postoperative analgesia was maintained with epidural PCA with a similar solution. Group Post-TEA, with no intraoperative medication, had the same postoperative analgesia as Group Pre-TEA plus the bolus dose. Group IV-PCA received only IV-PCA with morphine for postoperative analgesia. Pain was evaluated every 4 h during the first 48 h at rest, cough, and movement. Pre-TEA was associated with decreased pain compared with the other groups. Six months later, the patients were asked about their pain. The incidence and the intensity of pain were most frequent in Group IV-PCA (78%) and were the least in Group Pre-TEA (45%) (Group Pre-TEA versus Group IV-PCA, P = 0.0233; Group Pre-TEA versus Group IV-PCA, P = 0.014). Patients having pain on the second postoperative day had 83% chronic pain. TEA with preoperative initiation is a preferable method in preventing acute and long-term thoracotomy pain. IMPLICATIONS: Preoperatively initiated thoracic epidural analgesia has the most satisfying results in controlling postthoracotomy pain in the acute and long-term period, and it is associated with a decreased incidence (and intensity) of chronic pain compared with postoperative (epidural or IV) analgesia. Chronic pain has an incidence of 62%.     

Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery

BACKGROUND: Postoperative pain may be severe after coronary artery bypass surgery. High thoracic epidural analgesia (HTEA) provides intense analgesia. METHODS: Eighty patients were randomized to HTEA or intravenous morphine analgesia (control). Patients received coronary artery bypass surgery (CABG) with cardiopulmonary bypass. Pain was measured by visual analogue scale 0 to 10. Psychologic morbidity, intraoperative hemodynamics, ventricular function, lung function, and physiotherapy cooperation were also assessed. On the third postoperative day HTEA and morphine were ceased and only oral medications were used. Acetaminophen, indomethacin, and tramadol were allowed as supplemental analgesics in both groups. RESULTS: The primary endpoint of pain scores was significantly less with HTEA on postoperative days 1 and 2 at rest, 0.02 +/- 0.2 versus 0.8 +/- 1.8 (p = 0.008) and 0.1 +/- 0.4 versus 1.2 +/- 2.7 (p = 0.022), respectively, and with coughing 1.2 +/- 1.7 versus 4.4 +/- 3.1 (p < 0.001) and 1.5 +/- 2.0 versus 3.6 +/- 3.1 (p = 0.001), respectively. When HTEA and morphine were ceased on day 3, there were no significant differences. The secondary endpoints of postoperative depression (p = 0.033) and posttraumatic stress subscales (p = 0.021) of the Minnesota Multiphasic Personality Inventory were lower with HTEA. Extubation occurred earlier with HTEA, 2.6 versus 5.4 hours (p < 0.001). HTEA showed improved physiotherapy cooperation (p < 0.001), arterial oxygen tension (p = 0.041), and peak expiratory flow rate (p = 0.001). Mean arterial pressure was lower with HTEA (p = 0.036), otherwise there were no differences in intraoperative hemodynamics or ventricular function. CONCLUSIONS: Epidural analgesia reduces pain after coronary operation and is associated with improved physiotherapy cooperation, earlier extubation, and reduced risk of depression and posttraumatic stress.     

Quantitative sensory testing and human surgery: effects of analgesic management on postoperative neuroplasticity

BACKGROUND: Altered central nervous system sensory processing (neuroplasticity) is a basic mechanism underlying postoperative pain that can be made visible using quantitative sensory testing. Using quantitative sensory testing, the authors investigated how perioperative analgesia affects postoperative neuroplasticity and how this relates to clinical pain measures. METHODS: Patients undergoing back surgery received placebo, fentanyl, or ketorolac (n = 15 per group) before isoflurane-nitrous oxide anesthesia. Preoperatively to 5 days postoperatively, we measured thresholds to electrical skin stimulation at the incision site, arm, and leg; pain scores; and morphine patient-controlled analgesia consumption. RESULTS: Decreased pain thresholds versus preoperatively were seen 5 days postoperatively, with decreases greater for ketorolac (-63%; P = 0.00005 vs. preoperatively) than placebo (-45%; P = 0.008 vs. preoperatively) but nonsignificant for fentanyl (-36%; P = 0.9 vs. preoperatively). Mainly nonnociceptive thresholds were increased up to 24 h postoperatively. Postoperative clinical pain measures were similar across drug groups. Postoperative pain tolerance threshold changes did not correlate with preoperative clinical pain measures but were inversely related to preoperative thresholds for placebo and ketorolac but not fentanyl. CONCLUSIONS: Without analgesia, neuroplasticity after surgery was inhibitory the first 24 h and followed at 5 days by excitation. Fentanyl efficiently preempted this hyperalgesia, but hyperalgesia was greater with ketorolac than with placebo. Clinical pain measures neither reflected the different effects of ketorolac and fentanyl on postoperative neuroplasticity nor permitted prediction of postoperative neuroplasticity. The information obtained by perioperative quantitative sensory testing is separate from and additional to that from clinical pain measures and may enable more mechanism-based approaches to surgical analgesia management in the future.     

Preemptive bupivacaine offers no advantages to postoperative wound infiltration in analgesia for outpatient breast biopsy

BACKGROUND: Adequate analgesia is important after surgery and in particular after ambulatory surgery. Preemptive administration of analgesics, ie, prior to commencing surgery, has many theoretical advantages. METHODS: In this prospective randomized study, the use of preincisional bupivacaine was compared with a postincision dose for the relief of postoperative pain, in 74 patients undergoing day-case breast biopsy. RESULTS: Demographic criteria were similar in both groups. There were no differences in pain scores postoperatively on the visual analog scale (VAS): VAS at 30 minutes 4.5 ([SD] 2.4) versus 4.7 (1.9); P = not significant (NS); VAS at 60 minutes 3.3 (2. 3) versus 3.6 (2.2); P = NS; VAS at 120 minutes 1.9 (1.7) versus 2.5 (2.0); P = NS; VAS at 240 minutes 0.9 (1.0) versus 1.3 (1.4); P = NS. There was no difference in the number of patients requiring additional analgesia: 13 (36%) versus 18 (47%); P = NS. Nor was there a difference in the time to additional analgesia: 55.0 (37.8) versus 55.3 (39.2) minutes; P = NS. CONCLUSIONS: The administration of local anaesthesia prior to starting surgery does not appear to have any advantage over its postoperative administration in patients undergoing ambulatory breast biopsy.     

Efficacy and safety of radiofrequency ablation for perivascular hepatocellular carcinoma without hepatic inflow occlusion

BACKGROUND: The role of radiofrequency ablation (RFA) for perivascular (up to 5 mm from the major intrahepatic portal vein or hepatic vein branches) hepatocellular carcinoma (HCC) is unclear because of possible incomplete tumour ablation and potential vascular damage. This study aimed to evaluate the safety and efficacy of RFA for perivascular HCC without hepatic inflow occlusion. METHODS: Between May 2001 and November 2003, RFA using an internally cooled electrode was performed on 52 patients with perivascular HCC (group 1) through open (n = 39), percutaneous (n = 9), laparoscopic (n = 2) and thoracoscopic (n = 2) approaches. Hepatic inflow occlusion was not applied during the ablation procedure. The perioperative and postoperative outcomes were compared with those of 90 patients with non-perivascular HCC (group 2) treated by RFA during the same period. RESULTS: The morbidity rate was similar between groups 1 and 2 (25 versus 28 per cent; P = 0.844). One patient in group 1 (2 per cent) and two in group 2 (2 per cent) had developed thrombosis of major intrahepatic blood vessels on follow-up computed tomography scan. There were no significant differences between groups 1 and 2 in mortality rate (2 versus 0 per cent; P = 0.366), complete ablation rate for small HCC (92 versus 98 per cent; P = 0.197), local recurrence rate (11 versus 9 per cent; P = 0.762) and overall survival (1-year: 86 versus 87 per cent; 2-year: 75 versus 75 per cent; P = 0.741). CONCLUSION: RFA without hepatic inflow occlusion is a safe and effective treatment for perivascular HCC.