Perceptions of pain relief after surgery.

OBJECTIVE--To assess patients' satisfaction with postoperative pain relief. DESIGN--A descriptive and questionnaire study of patients' experience. SETTING--Two surgical and two gynaecological wards. PATIENTS--50 Patients admitted to hospital for cholecystectomy and 51 admitted for hysterectomy. MAIN OUTCOME MEASURES--Visual analogue scales with no divisions were completed by the patients immediately after each dose of postoperative analgesia was administered throughout their stay in hospital. A questionnaire completed on the fifth postoperative day recorded patients' recollections of their experience. Opinions were also sought from medical and nursing staff. RESULTS--During the first 24 hours after surgery recorded pain levels were 60% of the maximum and were not influenced by age, sex, or the type of operation performed. The median interval between the return of pain and a further injection of analgesic was 2 hours (interquartile range 1 to 3.5 hours). Expectations of pain relief were low, and for 70% of the patients the pain was at least as bad as they had expected. Only half of the medical and nursing staff questioned thought that postoperative analgesia should relieve pain completely; drugs were prescribed and administered with too little attention to the patient's response and too much concern about adverse effects and opioid dependence. CONCLUSIONS--The results suggest that the standard of postoperative pain relief is poor because of inadequate education of patients in what to expect (and demand), and of medical and nursing staff in how to prescribe and administer analgesia with reference to individual drug response.

Repeat radiosurgery for refractory trigeminal neuralgia.

OBJECTIVE: Stereotactic radiosurgery has become an important and minimally invasive alternative for patients with refractory trigeminal neuralgia. When a second procedure is necessary, the outcomes are unknown. The degree of pain relief and morbidity after repeat radiosurgery were studied. METHODS: Thirty-one patients underwent a second gamma knife radiosurgery procedure because of unsatisfactory or unsustained relief of pain after the first procedure. Twenty-seven patients were assessable at median follow-up periods of 42.7 and 20.4 months after the first and second procedures, respectively. Most patients had undergone multiple previous operations of other types (microvascular decompression, radiofrequency rhizotomy, glycerol rhizotomy, balloon compression). The median target doses of the first and second radiosurgeries were 75 and 64 Gy, respectively. All patients were evaluated by a physician who did not participate in patient treatment. RESULTS: After the first radiosurgical procedure, 13 patients had an excellent response initially (complete relief without any medication), 3 had a good response (complete relief with some medication), 7 had a fair response (>50% relief), and 4 had a poor response (<50% pain relief or treatment failure). Repeat radiosurgery was performed in patients with recurrent or residual pain. After the second radiosurgical procedure, 5 patients had an excellent response, 8 had a good response, 10 had a fair response, and 4 had a poor response. Thirteen patients (48%) achieved complete pain relief (with or without medication). Two patients (7.4%) experienced new sensory symptoms after the first radiosurgical procedure, and three (12.7%, actuarial) experienced new sensory symptoms after the second procedure. CONCLUSION: Repeat radiosurgery provided a similar rate of pain relief as the first procedure, despite a modest dose reduction. The risk of new sensory symptoms was increased, but no other morbidity was identified. For patients who experience recurrent pain and choose to undergo a second procedure, our current procedure is to deliver a maximum dose of 50 to 60 Gy to a trigeminal target anterior to the root entry zone near the entrance of the nerve beneath the petrous dura.

Pancreatoduodenectomy for chronic pancreatitis: long-term results in 105 patients.

HYPOTHESIS: For patients with head-dominant, small-duct chronic pancreatitis who require operative intervention, pancreatoduodenectomy can be performed safely and affords satisfactory pain relief in most. DESIGN: Retrospective case series. Follow-up was complete in 86% of study subjects (average, 6.6 years). SETTING: Tertiary care center. PATIENTS: Among 484 consecutive cases of chronic pancreatitis treated surgically from January 1976 through April 1997, 105 (22%) in which pancreatoduodenectomy was performed were reviewed with regard to criteria for selection, operative procedure, postoperative course. and long-term outcome. MAIN OUTCOME MEASURES: The main outcome measure was degree of pain relief. Additionally, late mortality, cause of death, the presence of endocrine and exocrine insufficiency, and quality of life were recorded. RESULTS: There were 72 men (69%) and 33 women (31%) with a mean age of 51 years (range, 24-77 years). The cause of chronic pancreatitis was alcohol related in 58 patients (55%) and idiopathic in 41 (39%). Clinical manifestations included abdominal pain in 86 patients (82%), obstructive jaundice in 27 (26%), and vomiting in 11 (11%). Suspicion of malignant neoplasm was a concern in 67 patients (64%). Operative morbidity was 32%, and mortality, 3%. Mean hospital stay was 16 days (range, 12-82 days). Survival was significantly lower than that of age-matched controls. Among 66 patients with preoperative pain, pain relief was achieved in 59 (89%); it was complete in 44 patients (67%) and partial in 15 (23%). Operation resulted in a significant increase in patients with normal functional status (73 patients [81%] vs 51 [49%]; P<.001). Forty patients (48%) had diabetes. Steatorrhea was observed in 39 patients (43%), while weight maintenance or gain occurred in 59 (66%). CONCLUSIONS: Pancreatoduodenectomy achieves pain relief and good quality of life in a large percentage of selected patients with small-duct, head-dominant disease and is especially useful when a malignant neoplasm must be excluded. Morbidity and mortality are acceptable in experienced hands. Onset of diabetes and steatorrhea, while reflecting the natural course of the disease, is likely accelerated by pancreatoduodenectomy.

Longitudinal V-shaped excision of the ventral pancreas for small duct disease in severe chronic pancreatitis: prospective evaluation of a new surgical procedure.

OBJECTIVE: The technique of longitudinal V-shaped excision of the ventral pancreas for small duct chronic pancreatitis is presented and its efficacy in terms of pain relief and improvement of quality of life is evaluated. SUMMARY BACKGROUND DATA: Small duct chronic pancreatitis has been regarded as a classical indication for more or less extensive resection, in which the therapeutic success of pain relief is offset by the considerable risk of significant perioperative mortality and morbidity and the burden of substantial loss of pancreatic function. METHODS: Thirteen patients with severe pain who were diagnosed with small duct pancreatitis (defined as maximal Wirsungian ductal diameter of 2 mm) underwent longitudinal V-shaped excision of the ventral pancreas. In addition to routine pancreatic workup, a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Assessment of exocrine and endocrine function included fecal chymotrypsin and the pancreolauryl test as well as oral glucose tolerance, serum concentrations of insulin, C-peptide, and hemoglobin A1c. The interval between symptoms and surgery ranged from 12 months to 10 years (mean, 5.4 years). Median follow-up was 30 months (range, 12-48 months). RESULTS: There were no deaths. Overall morbidity was 15.4%. In 92% of patients, complete relief of symptoms was obtained. Median pain score decreased by 95%. Physical status, working ability, and emotional and social functioning scores improved by 40%, 50%, 67%,, and 75%, respectively. Global quality-of-life index increased by 67%. Occupational rehabilitation was achieved in 69% of patients. Exocrine and endocrine pancreatic function was well preserved. CONCLUSIONS: In small duct chronic pancreatitis, longitudinal V-shaped excision of the ventral pancreas is a safe and effective alternative to resection procedures. The new technique provides pain relief and improvement of quality of life, thus offering the benefit of a resection procedure without its burden.

The role of percutaneous cordotomy in the treatment of chronic cancer pain.

The authors report on 53 cervical percutaneous cordotomies in 52 patients suffering from chronic unilateral cancer pain. The evaluation of the results is based upon the patient's report of complete pain relief. Immediate and long term pain relief as well as complications and mortality rate are analysed. Excellent surgical results were obtained in 73% after one week and in 63% 15 weeks after operation. The topographical distribution of pain seems to influence the pain relief; the location of the cancer does influence the nature of the complications. Furthermore, the occurrence of other pain syndromes, controlateral to or above the level of analgesia, is evaluated. This appears to be an important limitation of the usefulness of cordotomy.

Electroanalgesia by transcutaneous stimulation (TNS). Response to the naloxone test

The authors, after a review of the literature about TNS, suggest the comparison between three different TNS techniques from two points of view: A) pain relief estimate; B) Response to Naloxone Test. To this purpose a impulse generator delivered a biphasic square-wave stimulus with duration of 0.40 msec and amplitude (peak to peak) to 130 mVolt, was used. TNS techniques used are so characterized 1) Frequency 80 Hz; Duration 30'; 2) Frequency 80 Hz; Duration over 120'; 3) Frequency 2/4 Hz; Duration over 120'. Although the techniques used for Group (1) provided the best numerical result in the evaluation of the pain relief, endorphine activity cannot be maintained owing to Naloxone Test negativity. pain relief of (2) and (3) Group was statistically significant although not numerically at the same level of (1) Group. In the laters, on the contrary, positivity of Naloxone Test seems to hint at the activation of endorphine. This fact suggest to the authors hypothesis in the purpose to spot TNS site of action.

Surgical management of chronic pancreatitis: long-term results in 141 patients.

The management of pancreatic pain is a controversial subject and the treatment recommended varies from one extreme to the other. Some authorities advise simply waiting for chronic pancreatitis to 'burn out', while others practise removal of the entire gland. In this paper we present 141 patients who underwent surgery for chronic pancreatitis at the Mayo Clinic. The main indication for operation was pancreatic pain and the choice of operation was based on anatomical abnormalities in the gland. The long-term results of the policy are reviewed (mean follow-up 8.5 years). Length of history, aetiology of disease, pancreatic dysfunction and pathology, time after operation and continued alcohol abuse were computer analysed for a statistically significant influence on pain relief, ability to work, pancreatic function and survival. There was one operative death (mortality rate 0.7 per cent). Continued drinking was not shown to affect postoperative pain relief but 10-year survival was significantly less in alcoholics than in those with non-alcoholic pancreatitis (P less than 0.02). Dilated ducts and duct calculi were associated with good results for pain relief although this association did not achieve statistical significance. Parenchymal calcification and time after operation did not influence the results of surgery. When the operation failed to relieve pain, spontaneous remission occurred in a few cases only. Seventy-seven per cent of patients had lasting relief of pain and operations selected on the basis of gross pathology were equally effective in relieving pain. Longitudinal pancreaticojejunostomy in those with dilated ducts and a Whipple operation for disease of the pancreatic head gave good results.(ABSTRACT TRUNCATED AT 250 WORDS)

Minimally invasive 360 degrees instrumented lumbar fusion.

A retrospective preliminary study was undertaken of combined minimally invasive instrumented lumbar fusion utilizing the BERG (balloon-assisted endoscopic retroperitoneal gasless) approach anteriorly, and a posterior small-incision approach with translaminar screw fixation and posterolateral fusion. The study aimed to quantify the clinical and radiological results using this combined technique. The traditional minimally invasive approach to the anterior lumbar spine involves gas insufflation and provides reliable access only to L5-S1 and in some cases L4-5. A gas-mediated approach yields many technical drawbacks to performing spinal surgery. A minimally invasive posterior approach involving suprafascial pedicle screw instrumentation has been developed, but without wide-spread use. Translaminar facet fixation may be a viable alternative to transpedicular fixation in a 360 degrees instrumented fusion model. Past studies have shown open 360 degrees instrumented lumbar fusion yields high arthrodesis rates. The study examined the cases of 46 patients who underwent successful 360 degrees instrumented lumbar fusion using a combined minimally invasive approach. Anterior lumbar interbody fusion (ALIF) at one or two levels was performed through the BERG approach; a gasless retroperitoneal approach to the lumbar spine allowing the use of standard anterior instrumentation. Posteriorly, all patients underwent successful decompression, translaminar fixation, and posterolateral fusion at one or two levels through one small (2.5-5.0 cm) incision. Results showed mean hospital stay of 2.02 days; mean combined blood loss was 255 cc; and mean pain relief was 56%, with 75.5% of patients reporting good, excellent, or total pain relief. Forty-two of 46 patients (93.2%) achieved a solid fusion 24 months after surgery. A total of 47% of all patients working prior to surgery returned to work following surgery. The study showed that minimally invasive 360 degrees instrumented lumbar fusion, when performed utilizing these approaches, yields a high rate of solid arthrodesis (93.3%), good pain relief, short hospital stays, low blood losses, accelerated rehabilitation, and a quick return to the workforce. The BERG approach offers technical advantages over the traditional gas-mediated laparoscopic approach to the anterior lumbar spine.

Lumbar microdiscectomy in the elderly patient.

This study retrospectively analysed 60 patients who had undergone microsurgical lumbar discectomy at an age of > or = 60 years. The results were compared with those obtained in 44 discectomy patients who were operated on during the same study period, but not selected for age. Sixty-five operations were performed on the elderly group and 49 on the age comparison group. Patients were scored for pain relief in a short-term follow-up (2 months) using office visit records. Long-term follow-ups [mean 6.5 years (elderly) vs 8.8 (comparison) years], obtained by a mailed questionnaire, quantified leg and back pain and scored success in return to normal activities (RTA) and satisfaction with the results of surgery. In the short-term, overall pain relief was highly successful and not significantly different in both group [94% (elderly), 98% (comparison)]. Long-term follow-up yielded the following successful outcomes (elderly, comparison groups): leg pain relief (91%, 86%), back pain relief (76%, 76%), RTA (68%, 87%), and satisfaction (81%, 91%). As with other pre- and postoperative parameters, these differences were not statistically significant. As the proportion of older individuals continues to rise in developed countries, physicians are increasingly faced with geriatric patients whose symptoms are caused by herniated lumbar discs. The present study indicates that microsurgical discectomy for relief of this condition can be performed safely and effectively on these older patients.

Near-total pancreatectomy for chronic pancreatitis.

Eighty-seven patients underwent distal subtotal or near-total (80% to 95%) pancreatectomy (NTP) during a 25-year period for management of intractable pain resulting from chronic pancreatitis. Alcoholism affected the majority of patients and 20% of cases were idiopathic in origin. Ten patients (12%) exhibited insulin-requiring diabetes before operation. The perioperative mortality rate was 3.4%. Significant improvement or complete pain relief was achieved in 75% of patients while 14% remained narcotic dependent. Forty-four patients (51%) required insulin postoperatively, with an average insulin requirement of 35 U per day. Thirty late deaths occurred 2 to 15 years after operation, 12 (40%) of which were related to complications of pancreatic insufficiency or persistent alcoholism. Five patients (8.5%) required completion pancreatectomy 6 months to 4 years after NTP for complications relating to persistent pancreatitis. NTP provides effective pain relief in the majority of patients with chronic pancreatitis. While this procedure can be performed with a low operative mortality rate, the high incidence of endocrine and exocrine insufficiency after operation may contribute to late deaths. Consequently, this procedure should be performed only when the underlying disease has functionally destroyed the pancreas or when lesser procedures have failed to provide adequate pain relief.