Flat Panel Fluoroscopy (O-Arm) Guided Percutaneous Radiofrequency Anterolateral Cordotomy

INTRODUCTION Chronic pain is a major cause of the current opioid epidemic in the United States. Cancer related intractable pain represents a challenging condition to manage medically. Most patients with this condition need increasingly higher doses of opioid analgesics due to receptor downregulation. This put patients at risk of opioid addiction, and it results in financial burden on both the patients and healthcare system. Anterolateral cordotomy is an ablative pain procedure that works through interrupting the ascending pain pathways contralateral to the pain site, namely the spinothalamic tract. Here, we present a case with unilateral cancer related somatic pain that was treated with a contralateral C1-C2 cordotomy. METHODS A 55-yr-old female with a stage 4 breast cancer that invaded her chest wall and axilla on the right side was studied. The tumor eroded through the skin of the breast. She has been having worsening chronic somatic pain that required hospital admission. She was using 60 mg of oral Methadone and 300 mg of Dilaudid delivered through patient control analgesia (PCA), with residual pain scored at 5 (1-10). She underwent a left sided C1-C2 O-arm guided percutaneous Radiofrequency cordotomy. RESULTS The patient had an immediate complete relief of her pain in the operating room that lasted throughout her hospital stay. On postop day 1 the Dilaudid was cut down by 50%. On postop day 2 it was stopped, and the patient was continued on oral protocol. She was discharged home on postop day 3. Neurologically the patient had no pain/temperature sensation on the right arm and chest, but she maintained motor strength, proprioception, vibration, and balance equally on both sides. CONCLUSION O-arm guided percutaneous Radiofrequency cordotomy is an effective minimally invasive method to treat chronic somatic pain. It results in immediate pain relief in 90% of patients with resultant reduction in opioids consumption and decrease hospital length of stay.

FA08.02: ENHANCED RECOVERY AFTER ESOPHAGECTOMY AND RECONSTRUCTION FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Background Enhanced recovery after surgery (ERAS) was originally designed and used in colorectal surgery. Recently there were some related reports of its implementation on esophageal cancer surgery, mainly adenocarcinoma. This study is to determine if ERAS can be effectively and safely applied to esophageal squamous cell carcinoma in Asian population. Methods In early 2012, our perioperative management protocol was reinvented and has been implemented thereafter. So two groups of patients were set up and compared. Group A is the patients operated on before 2012, managed by the old protocol. Group B is the patients managed under the new protocol. Their demographics, complications, hospital stay and charges were reviewed and analysed. Results Group A 65 patients. Group B 61 patients. The ventilator days, ICU stay and postoperative stay were statistically shorter in group B. There was no hospital mortality in either groups. No increase of complications was noted in group B. The hospital charges in group B were lower although statistically insignificant. Conclusion The new protocol of perioperative care is safe and effectively enhanced the postoperative recovery after esophagectomy and reconstruction for esophageal squamous cell carcinoma. Table 1. Clinical protocol for group A and B POD, post-operative day; ICU, intensive care unit; TPN, total parenteral nutrition; J-P drain, Jackson-Pratt drain; N/S, normal saline; CVC, central venous catheter; NG, nasogastric tube; OR, operating room; NPO, nil per os; IV, intravenous; PCA, patient control analgesia. Disclosure All authors have declared no conflicts of interest.

Post-Operative Pulmonary Function : A Comparison between Upper Abdominal Open Cholecystectomy and Laparoscopic Cholecystectomy

Postoperative Pulmonary Complications (PPCs) is one of the major cause of perioperative mortality and morbidity in thoracic and upper abdominal surgery. Preoperative risk assessment enables clinicians to reduce perioperative risk in high risk patients.. In upper abdominal surgery, there is a larger alteration in pulmonary functions. This study was performed in 30 patients scheduled for laparoscopic cholecystectomy and for upper abdominal open cholecystectomy. The study revealed that after both laparoscopic & open upper abdominal cholecystectomy there was significant alteration of pulmonary function. There was significant alteration at six hours and after operation which then gradually improved, but it took about 24 hours for its complete recovery. The alteration was more evident in open cholycystectomy. Nevertheless these alterations did not cause any clinical derangement as expressed by SpO2, HR, & BP. The study also showed a significant dose reduction of opioid in case of laparoscopic cholecystomy. The lung function at postoperative ward correlated well with the level of analgesia. But persistent alteration of pulmonary function indicated presence of other mechanical factors. Key Words: Surgery-Lap.Cholecystectomy, Surgery- Upper abdominal, Complication-post- Operative, complication-pulmonary, Patient control analgesia Journal of BSA, Vol. 17, No. 1 & 2, 2004 p.12-16DOI: http://dx.doi.org/10.3329/jbsa.v17i1.4045

Polymorphism of μ-Opioid Receptor Gene (OPRM1:c.118A>G) Might Not Protect against or Enhance Morphine-Induced Nausea or Vomiting

A cohort, double blind, and randomized study was conducted to investigate the effect of a single nucleotide polymorphism of the μ-opioid receptor at nucleotide position 118 (OPRM1:c.118A>G) on the association with the most common side effects (nausea or vomiting) induced by intravenous patient control analgesia (IVPCA) with morphine, including incidence and severity analysis. A total of 129 Taiwanese women undergoing gynecology surgery received IVPCA with pure morphine for postoperative pain relief. Blood samples were collected and sequenced with high resolution melting analysis to detect three different genotypes of OPRM1 (AA, AG, and GG). All candidates 24 h postoperatively will be interviewed to record the clinical phenotype with subjective complaints and objective observations. The genotyping after laboratory analysis showed that 56 women (43.4%) were AA, 57 (44.2%) were AG, and 16 (12.4%) were GG. The distribution of genotype did not violate Hardy-Weinberg equilibrium test. There was no significant difference neither between the severity and incidence of IVPCA morphine-induced side effects and genotype nor between the association between morphine consumption versus genotype. However, there was significant difference of the relation between morphine consumption and the severity and incidence of IVPCA morphine-induced nausea and vomiting. The genetic analysis for the severity and incidence of IVPCA morphine-induced nausea or vomiting showed no association between phenotype and genotype. It might imply that OPRM1:c.118A>G does not protect against IVPCA morphine-induced nausea or vomiting.