Early and Late Functional Outcomes of Anal Sphincter-Sparing Procedures With Total Mesorectal Excision for Anorectal Adenocarcinoma

Purpose: The study aims to assess the functional outcome of anal sphincter-sparing procedures (SSP) with total mesorectal excision (TME) for anorectal adenocarcinoma.Methods: In a multicentric, prospective, single-group study in the period between December 2012 and November 2017, 93 patients presented with anorectal adenocarcinoma were included in the study. Sixty-nine patients underwent SSP with TME. SSP included the combined approach of transabdominal TME with intersphincteric resection (ISR) or transanal transabdominal TME. Using the per anal examination scoring system (PASS), postoperative anal function was assessed after 1 year.Results: Bowel motility time was 50±19 hours. The time needed for narcotic analgesia was 54±18.8 hours. Mean hospital stay was 15.4±10.25 days. Incidence of evident fecal incontinence after ISR is 10.6% (7 of 67 cases). The PASS findings of 69 cases are as follows: extremely hypotonic 8.6% (6 cases), slightly hypotonic 26.1% (18 cases), normal tone 58% (40 cases), slightly stenotic 3 cases (4.3%), or occluded 2.9% (2 cases). Urinary dysfunction occurred in 1 case (1.4%). Temporary diversion was performed in 61 patients (87.1%).Conclusion: Sphincter preservation with TME for anorectal adenocarcinoma helps avoid permanent stoma and provides reasonable functional outcomes. PASS is a new application for postoperative assessment of anal function.

Efficacy of Intraprocedural Superior Hypogastric Nerve Block in Reduction of Postuterine Artery Embolization Narcotic Analgesia Use

Purpose: Uterine artery embolization (UAE) is an effective treatment for the management of symptomatic uterine fibroids. We aim to evaluate the efficacy of superior hypogastric nerve block (SHNB) in reducing narcotic analgesia use for postprocedural pain after UAE. Methods: A retrospective review of 88 consecutive patients with symptomatic fibroids who underwent UAE between August 2015 and August 2018 was performed. A total of 44 patients had intraprocedural SHNB and 44 patients had no SHNB. They were placed on a morphine patient-controlled anesthesia (PCA) pump after the procedure and were admitted for overnight observation. The total amount of PCA narcotic analgesia received was recorded for each patient. Additional factors including fibroid size, fibroid location, and patient age were evaluated to determine the predictors of narcotic use reduction after SHNB. Results: The mean amount of postprocedural morphine use was 51.7 mg in patients who did not receive an SHNB versus 35.9 mg in patients who did receive an SHNB ( P = .008), resulting in a 47.2% reduction in narcotic analgesia use in the SHNB cohort. A significant reduction in morphine use with SHNB was associated with fibroid size greater than 5 cm ( P = .009), intramural fibroid location ( P = .04), and patients 45 years or younger ( P = .006). Conclusion: The use of SHNB could significantly reduce the amount of narcotic analgesia required for pain control after UAE with larger intramural fibroids and younger patients as predictors of increased efficacy.

Achieving Opioid-Free Major Colorectal Surgery: Is It Possible?

Introduction: Opioid analgesia remains the mainstay of postoperative pain management strategies despite being associated with many adverse effects. A specific opioid-free protocol was designed to limit opioid usage. Objective: The aim of the study was to audit the opioid-free rate within this protocol and to identify factors that might contribute to opioid-free surgery. Methods: A retrospective study of all elective patients receiving abdominal colorectal surgery at the Center for Colon and Rectal Surgery at AdventHealth over 6 months was performed. Data on demographics, indications, perioperative management, outcomes, and inpatient and outpatient analgesic requirements were collected with subsequent analysis. Results: A total of 303 consecutive patient records were analyzed. Approximately two-thirds (67.7%) of patients did not receive narcotics once they left the postanesthesia care unit as an inpatient. One-third of patients (32.0%) did not receive narcotic analgesia within 30 days of surgery as an outpatient. Patients in the opioid-free cohort were significantly older and had a malignant indication, less perioperative morbidity, and a shorter length of stay. Conclusions: Our study demonstrates that opioid-free analgesia is indeed possible in major colorectal surgery. Study limitations include its retrospective nature and that it is from a single institution. Despite these limitations, this study provides proof of concept that opioid-free colorectal surgery is possible within a specific protocol.

Preoperative Education Significantly Decreases Postoperative Opioid Use after Arthroscopic Meniscectomy

Objectives: Arthroscopic meniscectomy is one of the most common procedures in orthopedic surgery and is thus a frequent reason for prescription of post-operative opioid narcotics. Recent emphasis has been placed on limiting the number of opioid pills given for post-operative analgesia, with the goal being to provide adequate post-operative pain control while minimizing the number of unused pills after surgery. A number of modifiable variables have been identified to prevent over-prescription of opioids including prescriber education and identification of patient-specific factors associated with increased opioid use. To date, no study has evaluated the role of patient education to decrease post-operative opioid use. The goal of this study is to determine the utility of pre-operative patient education in decreasing post-operative opioid consumption after arthroscopic meniscectomy. Methods: All patients 18 years and older from a group of five attending surgeons undergoing isolated arthroscopic unicompartmental meniscectomy were prospectively identified for inclusion in this cohort study. Patients were split into two groups: patients in Group 1 did not receive any specific education regarding opioid usage after surgery while patients in Group 2 received a formalized three-minute overview from a physician on both appropriate usage of opioid narcotics as well as options for non-narcotic post-operative analgesia. Patients were assigned to each group consecutively - all patients at the beginning of the study were assigned to Group 1 while all patients at the end of the study were assigned to Group 2. Post-operatively, patients in both groups were surveyed via phone call one, two, three, and four weeks after surgery to determine the number of opioid pills taken each week. Patient descriptive statistics and post-operative opioid consumption were analyzed and compared between the two groups. Results: 62 patients completed the study, with 32 in Group 1 (no pre-operative education) and 24 in Group 2 (received pre-operative education). There were no significant demographic differences between the two groups. Patients in Group 1 used an average of 16.71 (95% CI, 9.67-23.75) opioid pills after surgery while patients in Group 2 used an average 3.21 (95% CI, 1.78-6.06) opioids after surgery. Patients in Group 2 used 13.5 less opioid pills (p = 0.001) representing a 420.0% decrease in post-operative opioid consumption over a four-week course (Figure 1). 7 (21.9%) patients in Group 1 continued to take opioid pills four weeks after surgery, while only 1 (4.2%) patient in Group 2 did the same. Conclusion: Pre-operative patient education regarding appropriate usage of opioid and options for non-narcotic analgesia significantly decreases post-operative opioid consumption and the duration which patients take opioid pills after arthroscopic meniscectomy. Pre-operative education is quick and inexpensive method to decrease post-operative opioid prescription requirements. [Figure: see text]

Postoperative Oxygen Desaturation

This case focuses on the benefits of using regional anesthesia vs. continuous administration of opioids by asking the question: What are the effects of regional anesthesia vs. continuous administration of opioids on respiratory function following general anesthesia for major surgery? This study demonstrated that narcotic analgesia is an important cause of oxygen desaturation and ventilatory disturbances during sleep in postoperative patients. The transient nature of desaturations and ventilatory disturbances highlighted the need for continuous monitoring techniques in the postoperative period.

A Prospective Randomized Study Evaluating the Effect of Perioperative NSAIDs on Opioid Consumption and Pain Management After Ankle Fracture Surgery

Category: Trauma Introduction/Purpose: Currently there is an epidemic in the United States regarding opioid abuse. This has resulted in strict government prescribing regulations throughout the country and increasing efforts by orthopaedic surgeons to better manage postoperative narcotic analgesia. Non-steroidal anti-inflammatory drugs (NSAIDs) can serve as a powerful adjunct in managing postoperative pain and in turn minimize the need for opioid medications. It has recently been shown that ketorolac can be used after open reduction and internal fixation (ORIF) of ankle fractures without interfering with bone healing. Therefore, we set out to evaluate whether including ketorolac in the postoperative drug regimen reduces opioid consumption and pain after ORIF of ankle fractures. Methods: 128 patients undergoing ORIF of an ankle fracture were prospectively randomized to treatment with or without ketorolac. Patients also had the option to simultaneously undergo regional anesthesia. Patients assigned to the treatment group were given 30 mg of IV ketorolac intraoperatively; prescribed 20 tablets of ketorolac 10 mg PO Q6 H and 30 tablets of Oxycodone/Acetaminophen 5/325 Q4-6 H PRN. Patients assigned to the control group were given 30 tablets of oxycodone/acetaminophen 5/325 Q4-6 H PRN only. A survey was distributed via Research Electronic Data Capture (REDCap) on postoperative days 1-7. Patients were asked to report their daily opioid consumption, pain level using the Visual Analog Scale (VAS), satisfaction with pain management, and side effects. Intention-to-treat analysis was performed. Normality of data was tested using the Shapiro-Wilk test. Differences between the control and treatment groups were tested using Mann-Whitney U or Student’s t-tests. Results: 105/128 (82%) patients with mean BMI of 29.3 completed all study requirements. 54 received ketorolac with opioid medication and 51 received opioids alone. 43 men (41%) and 62 women (59%) participated with mean age of 48 years. Patients receiving ketorolac required less oxycodone/acetaminophen (p<0.013) and reported less pain (p<0.048) during postoperative days 1 and 2 compared to control patients(Figure 1). While opioid consumption did not significantly differ after day 2, patients treated with ketorolac maintained less pain (days 1-4, p<0.028); better sleep (days 1-5, p<0.037); lower frequency of pain (days 1-3; p<0.017); and greater satisfaction with pain management (days 1-3, p<0.047). Hypersensitivity was significantly less on day 1 (p=0.036) and paresthesias on day 3 (p=0.011). Surprisingly, there was no difference in nausea/constipation between groups (p>0.139). Conclusion: The addition of ketorolac to the postoperative drug regimen significantly reduced pain, while decreasing the use of opioid medication following ORIF of ankle fractures early in the postoperative period. Better pain management during postoperative days 1 and 2 is particularly important because patients on average consume the most opioids during this time. With the assurance that ketorolac does not interfere with bone healing, this NSAID is a valuable tool for helping patients manage postoperative pain with less narcotic analgesia.

Assessment of a Lateral Nasal Wall Block Technique for Endoscopic Sinus Surgery Under Local Anesthesia

Introduction With increasingly limited operative resources and patient desires for minimally invasive procedures, there is a trend toward local endoscopic procedures being performed in the outpatient clinic setting. However, there remain limited data supporting a technique to adequately anesthetize the lateral nasal wall and provide patient comfort during these procedures. The objective of this study is to assess the efficacy of a novel lateral nasal wall block for use in office-based endoscopic sinus surgery. Methods A prospective cohort study assessing consecutive patients undergoing office-based endoscopic sinus surgery using our described lateral nasal wall block anesthesia technique. Procedural patient comfort was assessed using the Iowa Satisfaction with Anesthesia Scale (ISAS), completed by participants immediately following an office-based endoscopic procedure and prior to discharge from clinic. Postoperative analgesic use was assessed at the first postoperative visit. Results Thirty-five consecutive patients undergoing office-based outpatient endoscopic sinus surgery for chronic rhinosinusitis (with and without polyps) were assessed. The mean ISAS score was 2.83 (95% confidence interval: [2.69, 2.97]). All participants (100%) agree or strongly agree that they were satisfied with their anesthesia care and would want the same anesthetic again. No participant required narcotic analgesia, and 80% used no oral analgesia following the procedure. Conclusions Recent advances in office-based endonasal surgical procedures must be accompanied by the assessment and validation of local anesthetic techniques. The described novel lateral nasal wall block is well tolerated, provides patient satisfaction, and allows for limited use of postprocedure oral analgesics.

Is celecoxib a useful adjunct in the treatment of post-tonsillectomy pain in the adult population? A randomised, double-blind, placebo-controlled study

Objective:To evaluate the efficacy and safety of celecoxib for pain management in post-tonsillectomy adult patients.Design:A randomised, double-blind, placebo-controlled, phase 3 clinical trial was conducted in an adult population (aged 18–55 years), with a parallel group design using an allocation ratio of 1:1.Methods:Eighty patients underwent elective tonsillectomy or adenotonsillectomy, operated on by one surgeon. They were discharged home with randomly assigned celecoxib or placebo, together with regular post-tonsillectomy medications (paracetamol and Endone). Pain scores were measured from post-operative days 1 to 10. All patients were assessed on post-operative days 5, 12 and 28.Results:There were no statistically significant differences in the daily or overall pain scores, the total intake of Endone, or the time taken to achieve freedom from pain after tonsillectomy between the study arms (n = 40 each arm). The celecoxib-treated group experienced significantly more vomiting (celecoxib vs placebo p < 0.001 (Mann–Whitney test), confidence interval = 0.57 to 0.76).Conclusion:Celecoxib usage was associated with significantly more vomiting and did not reduce narcotic analgesia requirement post-tonsillectomy.