Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis.

OBJECTIVE: The authors sought to provide a framework through outcome analysis to evaluate operations directed toward the intractable abdominal pain of severe chronic pancreatitis centered in the pancreatic head. Pancreatoduodenectomy (PD) was used as an example. SUMMARY BACKGROUND DATA: Head resection for severe chronic pancreatitis is the treatment of choice for a ductal system in the head obliterated by severe disease when associated with intractable abdominal pain. To evaluate the effectiveness of promising head resection substitutes for PD, a framework is necessary to provide a reference standard (i.e., an outcome analysis) of PD. METHODS: Inclusion criteria were severe chronic pancreatitis centered in the pancreatic head, intractable abdominal pain, and a main pancreatic duct obstruction or stricture resulting in absent drainage into the duodenum from the uncinate process and adjacent pancreatic head areas or the entire gland. Since 1986, 57 consecutive cases with these criteria underwent PD (47 head only and 10 total pancreatectomy). Clinical and anatomic predictor variables were derived from the history, imaging studies, and pathologic examination. These variables then were tested for association with the following outcome events gathered during annual follow-up: pain relief, onset of diabetes, body weight maintenance, and peptic ulceration. RESULTS: Operative mortality was zero. In 57 patients with a mean follow-up of 42 months, the 5-year outcome event for survival was 93% and the onset of diabetes was 32%. All new cases of diabetes occurred more than 1 year after resection. In 43 cases > or =1 year postoperative with a mean follow-up of 55 months, all patients indicated significant pain relief and 76% were pain free. pain relief was more common in patients with diabetes or in those patients with a pancreatic duct disruption. Death was more common in patients with diabetes. Weight maintenance was more common if preoperatively severe ductal changes were not present. Total pancreatectomy was associated with peptic ulceration. CONCLUSIONS: Using selection criteria, the outcome analysis standardized anatomic and clinical variables as to how they were associated with the outcome events (calibrated the effects of the operation with each variable). In these selected patients, PD is safe and significantly relieves pain. Sequelae are from diabetes, provided total pancreatectomy is avoided.

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.

Why do patients feel positive about patient-controlled analgesia?

We studied 200 patients to identify the aspects of their experience of patient-controlled analgesia (PCA) that made them feel 'extremely positive' about this technique. After PCA had been withdrawn, patients completed a questionnaire which included the following topics: pre-operative information, pain relief, the degree of control that PCA afforded the patient, side-effects and safety. Multiple regression analysis identified three factors of their experience which were associated uniquely with feeling 'extremely positive' about PCA: having better pain relief, not worrying about 'giving oneself too much drug' and not experiencing feeling 'peculiar in the head'. Control over pain relief, although highly correlated with feeling 'extremely positive' about PCA, was unimportant when these variables were controlled. Because of the well-recognised difficulties in measuring satisfaction with analgesic regimens, we suggest that a satisfaction score based on these variables would be a significant advance on existing methods.



Chronic pancreatitis: results of a protocol of management.

Thirty-five patients with chronic pancreatitis of varying cause have been treated according to a protocol first introduced in 1979. At the end of a mean follow up time of 2.1 years, only 54% of patients were found to have derived benefit defined by pain relief and improved quality of life. Patients with alcoholic pancreatitis did particularly poorly, and alcoholics who continued to drink almost never benefited. Patients with dilated pancreatic ducts were more likely to do well than those with small ducts, and pancreaticojejunostomy had a satisfactory record of pain relief. Patients with biliary pancreatitis generally did well with cholecystectomy and clearance of the common bile duct. The 40-80% pancreatectomy had a poor record for pain relief, and produced diabetes in the majority of patients in whom it was used. Nothing will reverse the established pathology of chronic pancreatitis, which remains an unsatisfactory condition to treat.

Trigeminal neuralgia: what are the important factors for good operative outcomes with microvascular decompression.

BACKGROUND: Microvascular decompression has been widely used as the first choice in treating trigeminal neuralgia, but in a few patients, facial pain cannot be effectively controlled by microvascular decompression. We sought to clarify the important factors for good operative outcomes. METHODS: We reviewed 62 patients with trigeminal neuralgia treated by microvascular decompression during the period 2000 through 2002, including clinical presentation, operative findings, techniques, and outcomes. Neurovascular conflicts were divided into single contact, contact and indentation, single adhesion, adhesion and indentation, and trigeminal nerve atrophy. Operative outcomes were graded into immediate postoperative complete pain relief (excellent), delayed postoperative complete pain relief (better), significant pain relief (good), and no response to microvascular decompression (poor). RESULTS: All patients' presentations were typical at the time of pain onset, but the symptom in 17 patients changed to atypical before surgery. During operation, single contact and single adhesion was found in 14 patients and 15 patients, respectively; contact or adhesion in combination with indentation was found in 7 patients and 18 patients, respectively; atrophy occurred in 8 patients. Postoperatively, immediate and delayed complete pain relief was achieved in 32 (51.6%) patients and 17 (27.4%) patients, respectively; 11(17.7%) patients got significant pain relief; and 2 patients showed no response. The overall rate of complete pain relief in patients with shorter duration, typical presentation, artery compression and complete decompression was higher than that in patients with longer duration, atypical presentation, venous compression, and incomplete decompression. CONCLUSIONS: Shorter duration, typical presentation, single artery compression, and complete decompression are the positive factors for better operative outcomes with microvascular decompression. Worse outcomes are usually related to venous compression, longer duration, and atypical presentation.

Pain management in a rheumatology department: a satisfaction survey.

OBJECTIVES: To evaluate the quality of pain management in a teaching hospital rheumatology department. METHODS: We conducted a satisfaction survey among all the patients admitted to the conventional rheumatology department of our teaching hospital over a 1-month period (88 patients with a mean length of stay of 5 d). The patients were asked to complete a questionnaire on the day of discharge. The professional staff was not informed of the survey. RESULTS: The mean pain severity score at admission (visual analog scale, VAS) was 7.76 +/- 1.76 and the mean score decrease with treatment was 7.27 +/- 2.81. Expected pain relief and actual pain relief were correlated (R = 0.39; P = 0.001). Nearly all the patients (96.1%) reported have been encouraged to communicate about their pain. Information on the treatment was given to 89.3% of the patients; no significant differences in pain severity or pain relief were found between the patients who did and did not receive this information. The patients were satisfied with their management by the physicians (VAS: 8.83 +/- 2.07) and nurses (VAS: 8.68 +/- 1.72). CONCLUSION: Satisfaction with pain management (a subjective criterion) was good in our patients. However, no validated tools for measuring satisfaction are available, and measurements should be repeated to look for improvements over time. Limitations to these results include the placebo effect, the influence of memory, and the effects of the behavior of hospitalized patients. A repeat survey is needed.

Postoperative intramuscular dextromethorphan injection provides postoperative pain relief and decreases opioid requirement after hemorrhoidectomy.

BACKGROUND: Previous studies have shown that dextromethorphan (DM) produces an analgesic/antihyperalgesic effect. This study was designed to examine whether postoperative DM intramuscular (i.m.) injection could reduce post-hemorrhoidectomy pain. METHODS: At the end of the surgery, patients in the study group (n = 30) were given an intramuscular injection of 40 mg DM and 20 mg chlorpheniramine (CPM) while in the study group (n = 30), the patients were given intramuscular 20 mg CPM only. Pethidine (1 mg/kg, i.m.) was prescribed for postoperative pain relief if required. The time to first pethidine injection, total pethidine consumption, worst pain score, and pethidine-related side effects were recorded for 48 h postoperatively. RESULTS: The time from the end of operation to the first pethidine injection was 5.4 +/- 1.6 h and 17.8 +/- 3.7 h (P = 0.006) in the control group and the study group, respectively. Total pethidine consumption was 139.5 +/- 11.5 mg and 77.5 +/- 12.2 mg (P < 0.001) in the control group and the study group, respectively. The worst VAS score was 7.5 +/- 0.2 and 7.1 +/- 0.2 (P = 0.09) in the control and the study groups, respectively. The number of patients who required pethidine injection was 29 and 21 (P < 0.005) in the control and the study groups, respectively. The number of patients who suffered pethidine-related side effects was 7 and 1 (P < 0.025) in the control and the study groups, respectively. CONCLUSIONS: We found that intramuscular DM given at the end of operation could provide good postoperative pain relief and decrease the pethidine requirement after hemorrhoidectomy.

Egg membrane as a new biological dressing in split-thickness skin graft donor sites: a preliminary clinical evaluation.

BACKGROUND: This preliminary investigation attempted to determine the effectiveness of egg membranes as a new biological dressing to promote infection-free healing and provide pain relief over split-thickness skin graft (STSG) donor sites. METHODS: Eighteen patients, with 28 STSG donor sites who were admitted to the LinKou Burn Center from August 1997 to July 1999, were selected for this trial. The bilateral thighs were the main donor sites for STSG. To compare different dressings, Surgilon, B.G.C. (beta-glucan collagen), and Biobrane were applied to the same donor sites, and epithelialization, pain relief, fluid accumulation, hematoma formation, and the occurrence of rejection or infection were monitored post-application. RESULTS: The average wound healing time with egg membrane application was 11.64 +/- 1.29 (range, 10 to 13) days. Meanwhile, the average wound healing times for B.G.C. (6 patients) and Biobrane (6 patients) were 14.5 +/- 0.84 and 14.0 +/- 0.63 days, respectively. Finally, Surgilon (16 patients) had the longest healing time, at 16 +/- 1.41 days. On average, complete pain relief was achieved by 7.3 +/- 0.70 days for egg membrane application, while for B.G.C., Biobrane, and Surgilon, complete pain relief occurred by 7.0 +/- 0.89, 6.0 +/- 0.63, and 10.0 +/- 0.37 days, respectively. Finally, no infection or rejection developed during healing. CONCLUSIONS: From this preliminary study, egg membrane may be an ideal STSG donor site dressing, as it possesses properties of pain relief, wound protection, promotion of healing, and low cost. However, the limited unit size must be overcome, and its clinical application for burn wounds should be studied.

Treatment of deafferentation pain by chronic stimulation of the motor cortex: report of a series of 20 cases.

Twenty patients with deafferentation pain were treated by chronic stimulation of the motor cortex. The central fissure was localized using stereotactic MRI and the motor cortex was mapped using intra-operative somatosensory evoked potentials. Seven patients with trigeminal neuropathic pain experienced definite pain relief varying between 40 and 100%. Ten patients had central pain secondary to central nervous system lesions. A satisfactory long-lasting pain control (pain relief > 40%) was obtained in five of them (50% of cases). One patient with pain from peripheral nerve injury obtained more than 80% pain relief. Two patients had pain from spinal cord lesions. One did not respond but the other obtained an excellent long-term result. The location of the effective stimulation plots was in agreement with the somatotopic maps of the primary motor cortex. One patient developed a small extradural haematoma which resolved spontaneously. None of the patients developed seizure activity. This study confirms the potential value of motor cortex stimulation in the treatment of certain forms of intractable pain, especially in cases with trigeminal neuropathic pain.