Anatomical Anal Stenosis after PPH: Insights from a Retrospective Study and Rat Model.

High-grade hemorrhoids are usually recommended to receive operational treatments. However, these traditional surgeries are associated with severe postoperative pain. A procedure for prolapse and hemorrhoids (PPH), a circular staple device, has been developed to improve short-term outcomes, including reducing the severity of postoperative pain. PPH, compared to conventional surgery, has been associated with the incidence of anatomical anal stenosis. The causes of stenosis after PPH are not yet clear. We first analyzed the complications of our patients with PPH, and then developed a rat model to verify the tension force of PPH using Hematoxylin-eosin, Masson's trichrome, immunohistochemistry, and immunofluorescence staining. Our clinical data showed that PPH significantly improved postoperative pain, but that it resulted in higher incidences of complications, including anal stenosis, than hemorrhoidectomy. We simulated the status of PPH and developed a rat model to verify PPH's tension force, including the scarring area and the deposition of proinflammatory factors, angiogenic factors, and fibrotic factors. The tension wound histological data showed more extensive granulation tissue and inflammatory cell infiltration and a thicker epidermis than the control group on day 12 post-operation and tension treatment. In addition to IL-1ß and IL-10 cytokines on day 3 and IL-1ß, IL-6, and IL-10 cytokines on day 12 post-operation in the tension group, two angiogenic factors, CD31 and VEGF-A, were found to have a more significant expression on day 7 post-operation in the tension group. The mean scar area was larger and the distribution of fibrotic proteins (collagen 1, α-SMA, CTGF, and MMP2) in the tension group was significantly broader than in the control on day 12 post-operation and tension treatment. Based on the findings of our animal model, the development of a lesser tensile force for PPH to decrease the deposition of proinflammatory factors, angiogenic factors, and fibrotic factors is urgently required.

Efficacy and safety of perioperative application of esketamine on postpartum depression: A meta-analysis of randomized controlled studies.

Postpartum depression (PPD) seriously impairs the physical and mental health of mothers and their offspring, so how to prevent the occurrence of PPD has essential significance. Esketamine is a common general anesthetic that produces rapid and sustained antidepressant effects. However, the efficacy and safety of perioperative esketamine administration for PPD prevention remain uncertain. We conducted a meta-analysis to determine the effect of perioperative intravenous esketamine on PPD. Randomized controlled trials were included. The primary outcome was the prevalence of PPD and postpartum Edinburgh Postnatal Depression Scale (EPDS) scores. Secondary outcomes included postoperative pain scores and esketamine-related adverse effects. Seven studies included 669 patients treated with esketamine and 619 comparisons. Esketamine could effectively reduce EPDS scores and the incidence of PPD after cesarean section. Even at 42 days postpartum, the incidence of PPD was still significantly lower in the esketamine group. Esketamine did not increase the incidence of postoperative nausea and vomiting, dizziness, and drowsiness. In the esketamine low-dose subgroup, postoperative nausea and vomiting were significantly lower in the esketamine group. The two groups had no significant difference in postoperative pain scores. In conclusion, using esketamine during the perioperative period can reduce the incidence of PPD without increasing adverse effects.

Retrospective analysis of neurological findings in esophageal atresia: Allostatic load of disease complexity, cumulative sedation, and anesthesia exposure.

BACKGROUND: There is limited knowledge regarding the impact of perioperative critical care on frequency of neurological imaging findings following esophageal atresia (EA) repair. METHODS: This is a retrospective study of infants (n = 70) following EA repair at a single institution (2009-2020). Sex, gestational age at birth, type of surgical repair, underlying disease severity, and frequency of neurologic imaging findings were obtained. We quantified the length of postoperative pain/sedation treatment and anesthesia exposure in the first year of life. Data were presented as numerical sums and percentages, while associations were measured using Spearman's Rho. RESULTS: Vertebral/spinal cord imaging was performed in all infants revealing abnormalities in 44% (31/70). Cranial/brain imaging findings were identified in 67% (22/33) of infants in the context of clinically indicated imaging (47%; 33/70). Long-gap EA patients (n = 16) received 10 times longer postoperative pain/sedation treatment and twice the anesthesia exposure compared with short-gap EA patients (n = 54). The frequency of neurologic imaging findings did not correlate with underlying disease severity scores, length of pain/sedation treatment, or cumulative anesthesia exposure. Lack of associations between clinical measures and imaging findings should be interpreted with caution given possible underestimation of cranial/brain findings. CONCLUSIONS: We propose that all infants with EA undergo brain imaging in addition to routine spinal imaging given the high burden of abnormal brain/cranial findings in our cohort. Quantification of pain/sedation and anesthesia exposure in long-gap EA patients could be used as indirect markers in future studies assessing the risk of neurological sequelae as evidenced by early abnormalities on brain imaging.

Does Chewing Gum Lead to Earlier Postoperative Gastrointestinal Recovery in Children? A Systematic Review and Meta-analysis.

INTRODUCTION: Postoperative ileus is a common occurrence among children undergoing major operations, including gastrointestinal and spinal surgeries. Preliminary evidence in adults suggests that chewing gum plays a role in accelerating the return of postoperative gastrointestinal function. However, evidence is scarce in the paediatric population. The aim of this study was to investigate whether chewing gum has benefits for children. METHODS: We searched PubMed, Medline, Embase, and Cochrane Trials databases for randomised controlled trials that compare gum chewing with standard care after elective surgery in children from 1st Jan 2005 to 31st July 2021. We assessed the identified trials for quality and performed a systematic review and meta-analysis in accordance with PRISMA and registered in PROSPERO (CRD42022358801). The main outcome measures examined were time to flatus and stool postoperatively, time to tolerate oral intake, and length of hospital stay, which were analysed using fixed effects models. We also examined clinical complication rates and postoperative pain control. RESULTS: We included six eligible trials, with a total of 357 enrolled patients. The intervention was well tolerated without complications. There was no significant difference in time to flatus (-2.86 h; 95 % CI: -6.2 to 0.47 h, p = 0.09), time to stool (-6.39 h; 95 % CI: -13.9 to 1.2 h, p = 0.1), time to tolerate oral intake (-0.03 days; 95 % CI: -0.15 to 0.1 days, p = 0.68), and length of hospital stay (0.08 days; 95 % CI: -0.07 to 0.22 days, p = 0.29). Postoperative pain control (opioid consumption, pain score, nausea score) was similar in both groups (p > 0.05). CONCLUSION: Current evidence demonstrates that gum chewing is not associated with earlier postoperative gastrointestinal recovery in children. Future adequately powered and well-designed trials are necessary to evaluate any clinical benefit of chewing gum for children and whether it could result differences in healthcare satisfaction. LEVEL OF EVIDENCE: I.

How to Modulate Peripheral and Central Nervous System to Treat Acute Postoperative Pain and Prevent Pain Persistence.

Chronic postoperative pain (CPSP) is a major issue after surgery, which may impact on patient's quality of life. Traditionally, CPSP is believed to rely on maladaptive hyperalgesia and risk factors have been identified that predispose to CPSP, including acute postoperative pain. Despite new models of prediction are emerging, acute pain is still a modifiable factor that can be challenged with perioperative analgesic strategies. In this review we present the issue of CPSP, focusing on molecular mechanism underlying the development of acute and chronic hyperalgesia. Also, we focus on how perioperative strategies can impact directly or indirectly (by reducing postoperative pain intensity) on the development of CPSP.

Comparison of post-operative pain and quality of life between total thoracoscopic surgery and conventional full-sternotomy for aortic valve replacement.

BACKGROUND: To compare the post-operative pain and quality of life of patients who underwent total thoracoscopic surgery (TTS) or conventional full-sternotomy (CFS) for aortic valve replacement (AVR). METHODS: We reviewed the records of 223 consecutive AVR patients with either TTS or CFS from January 2018 to December 2022. We used a visual analogue scale (VAS) and the Short Form-36 Health Survey (SF-36) to measure the post-operative pain and quality of life, respectively. We also compared the operative data and clinical outcomes between the two groups. RESULTS: The TTS group had lower adjusted mean VAS scores than the CFS group at all time points after surgery (at 1 to 3 days and at 3 and 6 months, p < .001 for all comparisons), indicating less pain. The TTS group also had higher mean SF-36 scores than the CFS group up to 6 months after surgery (p < .001 for all comparisons), indicating better quality of life. The operative time was similar between the two groups (p = .224), but the TTS group had longer cardiopulmonary bypass time and aortic cross-clamp time than the CFS group (p < .001). The TTS group had more pulmonary complications than the CFS group (p = .023). However, there were no significant differences in other major complications or mortality between the two groups. CONCLUSIONS: TTS is a safe and effective alternative to CFS for AVR. TTS resulted in less pain and better quality of life, especially in the early recovery period. However, further prospective randomized controlled studies are needed to confirm our findings.

The effects of a multidisciplinary pathway for perioperative management of patients with hip fracture.

OBJECTIVES: To determine if a multidisciplinary pathway focused on non-opioid pain management, delirium assessment, and resource utilization improved outcomes in geriatric hip fracture patients. The goal was to reduce opioid usage, consultation not congruent with guidelines, and increase use of regional anesthesia to reduce delirium and improve outcomes. METHODS: An observational study was performed on hip fracture patients before and after the intervention. Hospitalists were educated on indications for preoperative cardiac consultation and specialized preoperative cardiac testing according to evidence-based guidelines with the inpatient cardiology service. Additional education on multimodal analgesia, limiting opioids, and peripheral nerve blocks was provided by the acute pain service. Pre-intervention outcomes from 1 July 20171 July 2017 to 31 May 201831 May 2018 (N = 92) were compared to post-intervention outcomes from 1 July 20181 July 2018 to 31 May 201931 May 2019 (N = 98) and included delirium, length of stay, 30-day readmission rate, time from arrival to procedure start time, time to first physical therapy session, and completion of cardiology consult time. We examined adherence, use of nerve blocks, and pre- and post-operative pain scores and opioid use. RESULTS: Delirium was reduced from 50.0% (N = 46/92) to 28.6% (N = 28/98); p = 0.002. Postoperative opioid use (IV morphine milligram equivalents) decreased from an average of 57.2 mg (±67.7) to 42.6 mg (±58.2),P < .0001. There was a significant decrease in mean pre-operative (5.4 ± 4.14 to 5.05 ± 2.8, P < .0001) and post-operative pain scores (4.3 ± 5.2 to 3.2 ± 2.2, P < .0001). There was a significant reduction in time to cardiology consultation from 18 h] to 12 h ; p < .001). CONCLUSIONS: A multidisciplinary collaboration between hospitalists, anesthesiologists, and cardiologists for hip fracture patients was associated with a reduction in pain and delirium and time to cardiologist evaluation. Prospective studies focusing on additional patient-centered outcomes are warranted.

Geriatric Pain Protocol: Impact of Multimodal Pain Care for Elderly Orthopaedic Trauma Patients.

Hip fractures are costly, and associated complications are the leading cause of injury-related deaths in persons 65 years or older. Pain medications in this population can be more potent, have a longer duration of action, and have serious side effects (Chau et al., 2008). Hip fractures are projected to reach 6.26 million worldwide by 2050 (Gullberg et al., 1997; Kannus et al., 1996). Morrison et al. (2003) report that uncontrolled pain leads to increased hospital length of stay (LOS), delayed physical therapy, and long-term functional impairment. The Geriatric Pain Protocol (GPP) is Cedars-Sinai's multimodal pain management solution, addressing the needs of older adult inpatients who have suffered fractures. Can the implementation of GPP reduce the morphine milligram equivalents (MMEs) used, LOS, and postoperative outcomes compared with non-GPP patients? Study participants included hip fracture patients admitted between February 1, 2019, and March 5, 2021; data were collected prospectively from electronic medical records. Inclusion criteria were patients 65 years or older with a hip fracture sustained from a ground-level fall and surgical candidate. Participants were divided into two categories: Geriatric Fracture Program (GFP) and non-GFP, with physician participation in the GFP being the differentiating factor. End points included postoperative pain, postoperative opioid utilization, LOS, complications, and 30-day readmission rates. The Mann-Whitney U test and Fisher's exact test were used for data analysis. Spearman's rank-based correlation coefficient was used to assess associations. The GPP decreased MME daily totals on Days 1 and 2 and improved pain management compared with non-GPP patients. The MMEs were lower in the GPP group than in the non-GPP group for both Postoperative Day 1 (POD1) (p = .007) and POD2 (p = .043); Numerical Rating Scale (NRS) Pain on POD1 was lower in the GPP group (vs. non-GPP, p = .013). There were no group differences in NRS POD2 Pain or complications (all ps > .1). The study sample (N = 453) had no significant difference between sex and LOS (all ps > .3). Although not statistically significant, the 30-day readmission rate trended lower in patients treated in accordance with the GPP. Use of the multimodal GPP reduced pain levels and MME totals for older adult hip fracture inpatients. More data are needed to evaluate the efficiency of the proposed protocol. Future studies should explore the possibilities of using the GPP across the geriatric orthopaedic patient care continuum.

[Preliminary experience of gasless transoral vestibular robotic thyroidectomy].

Objective: To explore the feasibility and safety of the gasless transoral vestibular robotic thyroidectomy using skin suspension. Methods: The clinical data of 20 patients underwent gasless transoral vestibular robotic thyroidectomy in the Department of Otorhinolaryngology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University from February 2022 to May 2022 were retrospectively analyzed. Among them, 18 were females and 2 were males, aged (38.7±8.0) years old. The intraoperative blood loss, operation time, postoperative hospital stay, postoperative drainage volume, postoperative pain visual analogue scale (VAS) score, postoperative swallowing function swallowing impairment score-6 (SIS-6), postoperative aesthetic VAS score, postoperative voice handicap index-10 (VHI-10) voice quality, postoperative pathology and complications were recorded. SPSS 25.0 was used for statistical analysis of the data. Results: The operations were successfully completed without conversion to open surgery in all patients. Pathological examination showed papillary thyroid carcinoma in 18 cases, retrosternal nodular goiter in 1 case, and cystic change in goiter in 1 case. The operative time for thyroid cancer was 161.50 (152.75, 182.50) min [M (P25, P75), the same below] and the average operative time for benign thyroid diseases was 166.50 minutes. The intraoperative blood loss 25.00 (21.25, 30.00) ml. In 18 cases of thyroid cancer, the mean diameter of the tumors was (7.22±2.02) mm, and lymph nodes (6.56±2.14) were dissected in the central region, with a lymph node metastasis rate of 61.11%. The postoperative pain VAS score was 3.00 (2.25, 4.00) points at 24 hours, the mean postoperative drainage volume was (118.35±24.32) ml, the postoperative hospital stay was 3.00 (3.00, 3.75) days, the postoperative SIS-6 score was (4.90±1.58) points at 3 months, and the postoperative VHI-10 score was 7.50 (2.00, 11.00) points at 3 months. Seven patients had mild mandibular numbness, 10 patients had mild cervical numbness, and 3 patients had temporary hypothyroidism three months after surgery and 1 patient had skin flap burn, but recovered one month after surgery. All patients were satisfied with the postoperative aesthetic effects, and the postoperative aesthetic VAS score was 10.00 (10.00, 10.00). Conclusion: Gasless transoral vestibular robotic thyroidectomy using skin suspension is a safe and feasible option with good postoperative aesthetic effect, which can provide a new treatment option for some selected patients with thyroid tumors.

New prolonged opioid consumption after major surgery in Sweden: a population-based retrospective cohort study.

OBJECTIVE: Given that long-term opioid usage is an important problem worldwide and postsurgical pain is a common indication for opioid prescription, our primary objective was to describe the frequency of new prolonged opioid consumption after major surgery in Sweden and, second, to evaluate potential associated risk factors. DESIGN: Cohort study including data from 1 January 2007 to 31 December 2014. Data regarding surgical procedures, baseline characteristics and outcomes was retrieved from the Orbit surgical planning system, the Swedish national patient register and the Swedish cause of death register. SETTING: Observational multicentre cohort study with data from 23 Swedish hospitals. PARTICIPANTS: We included 216 877 patients aged ≥18 years, undergoing non-cardiac surgery, not exposed to opioids 180 days before and alive 12 months after surgery. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary endpoint was collection of at least three opioid prescriptions during the first postoperative year; within 90 days, day 91-180 and 181-365 after surgery in a previously opioid-naïve patient. Second, multivariable logistic regression analysis was conducted to explore potential risk factors associated with prolonged opioid use. RESULTS: Of the 216 877 patients identified to undergo analysis, 15 081 (7.0%) developed new prolonged opioid consumption. Several risk factors were identified. Having a history of psychiatric disease was identified as the strongest risk factor (adjusted odds ratio: 1.94; 95% CI: 1.87 to 2.00). CONCLUSION: In a large Swedish cohort of surgical patients, 7% developed new prolonged opioid consumption after major surgery. Our data on susceptible patients could help clinicians reduce the number of prolonged opioid users by adapting their analgesic and preventative strategies.

Long-term Efficacy of Pectoserratus Plane Block (PSPB) for Prevention of Post-mastectomy Pain Syndrome: Extended Follow-up From a Randomized Controlled Trial.

OBJECTIVES: Pectoserratus plane block (PSPB) leads to lower postoperative pain intensity. We examined whether PSPB could also reduce the incidence of post-mastectomy pain syndrome (PMPS) in women undergoing breast cancer surgery. METHODS: We performed an extension study of a randomized trial that compared PSPB versus control in women undergoing mastectomy. The primary outcome was any chronic pain at the surgical site or adjacent areas, defined as persistent/recurrent pain lasting ≥3 months. Secondary outcomes included neuropathic pain (score ≥4 in the Douleur Neuropathique 4 questionnaire), use of analgesic/anti-inflammatory drugs, pain intensity through the short-form McGill Pain Questionnaire, and type, frequency, and location of the pain. RESULTS: Of the 60 patients that completed the 24-hour follow-up (short-term trial), 53 (88%) completed the long-term follow-up (27 in the PSPB group and 26 in the placebo group). Six of 27 patients (22%) in the PSPB group and 17 of 26 patients (65%) in the placebo group reported any chronic pain (relative risk [RR], 0.34; 95% confidence interval [95% CI]=0.16-0.73, P =0.005). The risk of neuropathic pain was also lower in the PSPB group than in the placebo group (18.5% vs. 54%, respectively; RR, 0.34; 95% CI=0.14-0.82, P =0.02). There were no differences regarding all other pain-related outcomes considering the patients who developed PMPS. DISCUSSION: The results suggest that, in the long term, PSPB-treated participants were associated with a statistically significantly lower risk of PMPS than those who received standard general anesthesia. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03966326).

Correlation and influencing factors of preoperative anxiety, postoperative pain, and delirium in elderly patients undergoing gastrointestinal cancer surgery.

BACKGROUND: The correlation and influencing factors of preoperative anxiety, postoperative pain, and delirium in elderly patients undergoing gastrointestinal cancer surgery were explored with the Beck Anxiety Inventory (BAI) scale, 10-point Visual Analogue Scale (VAS), and Confusion Assessment Method Chinese Reversion (CAM-CR) scale. METHODS: A total of 120 patients aged 65 years old who receiving gastrointestinal cancer surgery were enrolled in the study. Perioperative anxiety, pain, and delirium were assessed by the BAI scale, VAS scale, and CAM-CR scale, respectively. The correlation and influencing factors of preoperative high anxiety, postoperative high pain, and postoperative delirium were analyzed. RESULTS: Preoperative high anxiety had a moderate positive correlation with postoperative high pain (P < 0.001, r = 0.410), and had a weak positive correlation with postoperative delirium (P = 0.005, r = 0.281). postoperative high pain had a weak positive correlation with postoperative delirium (P = 0.017, r = 0.236). Type of cancer and surgical approach were considered to be independent risk factors of preoperative high anxiety (P = 0.006 and P = 0.021). Preoperative high anxiety was considered to be an independent risk factor of postoperative high pain (P< 0.001). Age and preoperative high anxiety were considered to be independent risk factors of postoperative delirium (P< 0.001 and P = 0.010). CONCLUSIONS: Elderly patients undergoing gastrointestinal cancer surgery had a higher incidence of preoperative anxiety, as well as first-day postoperative pain and first-day postoperative delirium. Factors such as type of cancer, surgical approach and preoperative anxiety had been identified as influencing preoperative anxiety levels; preoperative anxiety had been linked to postoperative pain; and age and preoperative anxiety have been identified as influencing factors of postoperative delirium. TRIAL REGISTRATION: hiCTR2000032008, 17/04/2020, Title: "Effects of different analgesic methods on postoperative recovery of elderly patients with digestive tract tumor". Website: https://www.chictr.ogr.cn .

Cigarette smoking, opioid consumption, and pain intensity after major surgery: An observational study.

BACKGROUND: Chronic exposure to nicotine may change pain perception and promote opioid intake. This study aimed to evaluate the putative effect of cigarette smoking on opioid requirements and pain intensity after surgery. METHODS: Patients who underwent major surgery and received intravenous patient-controlled analgesia (IV-PCA) at a medical center between January 2020 and March 2022 were enrolled. Patients' preoperative smoking status was assessed using a questionnaire by certified nurse anesthetists. The primary outcome was postoperative opioid consumption within 3 days after surgery. The secondary outcome was the mean daily maximum pain score, assessed using a self-report 11-point numeric rating scale, and the number of IV-PCA infusion requests within three postoperative days. Multivariable linear regression models were used to calculate the regression coefficient (beta) and 95% confidence interval (CI) for the association between smoking status and outcomes of interest. RESULTS: A total of 1162 consecutive patients were categorized into never smokers (n = 968), former smokers (n = 45), and current smokers (n = 149). Current smoking was significantly associated with greater postoperative opioid consumption (beta: 0.296; 95% CI, 0.068-0.523), higher pain scores (beta: 0.087; 95% CI, 0.009-0.166), and more infusion requests (beta: 0.391; 95% CI, 0.073-0.710) compared with never smokers. In a dose-dependent manner, smoking quantity (cigarette per day) was positively correlated with both intraoperative (Spearman's rho: 0.2207, p = 0.007) and postoperative opioid consumption (Spearman's rho: 0.1745, p = 0.033) among current smokers. CONCLUSION: Current cigarette smokers experienced higher acute pain, had more IV-PCA infusion requests, and consumed more opioids after surgery. Multimodal analgesia with nonopioid analgesics and opioid-sparing techniques, along with smoking cessation should be considered for this population.

Problematic opioid use among osteoarthritis patients with chronic post-operative pain after joint replacement: analyses from the BISCUITS study.

OBJECTIVES: Opioids are commonly used to manage pain, despite an increased risk of adverse events and complications when used against recommendations. This register study uses data of osteoarthritis (OA) patients with joint replacement surgery to identify and characterize problematic opioid use (POU) prescription patterns. METHODS: The study population included adult patients diagnosed with OA in specialty care undergoing joint replacement surgery in Denmark, Finland, Norway, and Sweden during 1 January 2011 to 31 December 2014. Those with cancer or OA within three years before the first eligible OA diagnosis were excluded. Patients were allocated into six POU cohorts based on dose escalation, frequency, and dosing of prescription opioids post-surgery (definitions were based on guidelines, previous literature, and clinical experience), and matched on age and sex to patients with opioid use, but not in any of the six cohorts. Data on demographics, non-OA pain diagnoses, cardiovascular diseases, psychiatric disorders, and clinical characteristics were used to study patient characteristics and predictors of POU. RESULTS: 13.7% of patients with OA and a hip/knee joint replacement were classified as problematic users and they had more comorbidities and higher pre-surgery doses of opioids than matches. Patients dispensing high doses of opioids pre-surgery dispensed increased doses post-surgery, a pattern not seen among patients prescribed lower doses pre-surgery. Being dispensed 1-4,500 oral morphine equivalents in the year pre-surgery or having a non-OA pain diagnosis was associated with post-surgery POU (OR: 1.44-1.50, and 1.11-1.20, respectively). CONCLUSIONS: Based on the discovered POU predictors, the study suggests that prescribers should carefully assess pain management strategies for patients with a history of comorbidities and pre-operative, long-term opioid use. Healthcare units should adopt risk assessment tools and ensure that these patients are followed up closely. The data also demonstrate potential areas for further exploration in improving patient outcomes and trajectories.

Does the use of cooled saline irrigation during third molar surgery affect post-operative morbidity?

Design This study is a double-blind, single-centre, split-mouth, prospective randomised control trial. In total, 48 patients had bilateral third molars removed during two separate operations at least 21 days apart by the same maxillofacial surgeon. During the control operation, the tooth was irrigated with saline at 25°C. During the test operation, patients were randomised to tooth irrigation with saline at either 10°C (n = 24) or 4°C (n = 24). Local anaesthetic, flap design, burr design and sutures remained consistent throughout. Patients were prescribed amoxicillin, chlorhexidine and were advised to take paracetamol as needed. The patients remained blinded to which test group they were randomised to and to the order of the control or test operations performed. Participants self-recorded analgesia use and post-operative pain daily for seven days using a visual analogue scale (VAS). A second maxillofacial surgeon examined patients on days one, three and seven. Facial swelling was assessed by measuring the distance between various soft tissue points compared to pre-operative levels. Trismus was determined by measuring maximum inter-incisal opening compared to pre-operative levels.Case selection In total, 28 female and 20 male medically fit adult patients with a mean age of 24.6 ± 3.8 with bilateral mandibular asymptomatic third molar teeth were selected. Second molars with periodontal probing depths >4 mm or impacted third molars associated with cysts or tumours were excluded. Patients had no antibiotic prescription in the preceding month nor analgesic consumption in the 12 hours before surgery.Data analysis The Shapiro-Wilk test was used to evaluate if the sample fit a normal distribution. Relationships between the categorical variables of the groups was tested using chi-square statistics. Data comparisons were examined with the Duncan, Kriskal-Wallis, Dunn and Friedman test (p <0.05).Results The median duration of the control and test group operations were similar (p = 0.051). Test group patients reported lower pain VAS values and consumed less analgesics compared to the control groups (p = 0.001), with the lowest values seen in the 4°C group (p <0.001). A greater decrease in trismus levels was also seen on day three and seven in the test groups (p <0.001) compared to the control group (p = 0.07). Swelling was greatest in the control group (p <0.001) and reduced on day seven (p <0.001) in all groups. While trismus and swelling values were lower in the 10°C test group compared to the control (p <0.001), the lowest values of these parameters at all time points was in the 4°C group (p <0.001).Conclusions Early complications following third molar removal include facial swelling, trismus and pain. In this study, intraoperative cooled saline irrigation to 4°C and 10°C was more effective than saline irrigation at 25°C in reducing the intensity of these conditions.

Factores dependientes del paciente adulto y su relación con la hemorragia y el dolor postamigdalectomía en régimen ambulatorio / Dependent factors in the adult patient and their relationship with post-tonsillectomy bleeding and pain in an outpatient setting

Introducción y objetivo: La amigdalectomía realizada de forma ambulatoria en pacientes adultos presenta como principales complicaciones postoperatorias la hemorragia y el dolor.El seguimiento de directrices como la técnica quirúrgica fría, protocolos analgésicos, entrevista preoperatoria y seguimiento postoperatorio ayudan a un mejor control del proceso. No obstante, existen factores dependientes del paciente como el sexo, la edad, la indicación de la amigdalectomía y el tiempo transcurrido entre la última infección amigdalar y la intervención quirúrgica que pueden influir en las complicaciones postoperatorias y deben ser considerados.El objetivo de este trabajo es evaluar la influencia de la edad, el sexo, la indicación de la amigdalectomía y el periodo transcurrido entre la última infección amigdalar y la intervención quirúrgica sobre la hemorragia y el control del dolor.MétodosPara ello se realizó un estudio prospectivo, descriptivo, observacional, con 96 pacientes adultos que fueron intervenidos en régimen ambulatorio bajo anestesia general, empleando técnica quirúrgica fría, evaluando estas complicaciones en función de la edad, sexo, indicación para la amigdalectomía y el tiempo transcurrido tras la última amigdalitis.ResultadosLos pacientes intervenidos a lo largo de las cuatro semanas posteriores a un episodio de amigdalitis presentaron más dolor postoperatorio. No se encontró relación entre este periodo de tiempo y la hemorragia postoperatoria. (AU)

Introduction and objective: Tonsillectomy performed on an outpatient basis in adult patients presents bleeding and pain as main postoperative complications.Following rules such as cold surgical technique, analgesic protocols, preoperative interview, and postoperative follow-up help to better control the process. However, there are patient-dependent factors such as sex, age, indication for tonsillectomy and the time elapsed between the last tonsil infection and surgical intervention that can influence postoperative complications and should be considered.The objective of this work is to evaluate the influence of age, sex, the indication for tonsillectomy and the period elapsed between the last tonsil infection and surgery on bleeding and pain control.MethodsA prospective, descriptive, and observational study was carried out in 96 adult patients who underwent outpatient surgery under general anaesthesia, using cold surgical technique, evaluating these complications based on age, sex, indication for tonsillectomy and time elapsed after the last tonsillitis.ResultsThe patients operated on during the 4 weeks after an episode of tonsillitis presented more postoperative pain. No relationship was found between this period and postoperative bleeding.ConclusionsMale patients had a higher incidence of bleeding than women.The period elapsed between the last tonsil infection and the surgical procedure was associated with greater postoperative pain, but not with greater postoperative bleeding. (AU)

Dependent factors in the adult patient and their relationship with post-tonsillectomy bleeding and pain in an outpatient setting.

INTRODUCTION AND OBJECTIVE: Tonsillectomy performed on an outpatient basis in adult patients presents bleeding and pain as main postoperative complications. Following rules such as cold surgical technique, analgesic protocols, preoperative interview, and postoperative follow-up help to better control the process. However, there are patient-dependent factors such as sex, age, indication for tonsillectomy and the time elapsed between the last tonsil infection and surgical intervention that can influence postoperative complications and should be considered. The objective of this work is to evaluate the influence of age, sex, the indication for tonsillectomy and the period elapsed between the last tonsil infection and surgery on bleeding and pain control. METHODS: A prospective, descriptive, and observational study was carried out in 96 adult patients who underwent outpatient surgery under general anaesthesia, using cold surgical technique, evaluating these complications based on age, sex, indication for tonsillectomy and time elapsed after the last tonsillitis. RESULTS: The patients operated on during the 4 weeks after an episode of tonsillitis presented more postoperative pain. No relationship was found between this period and postoperative bleeding. CONCLUSIONS: Male patients had a higher incidence of bleeding than women. The period elapsed between the last tonsil infection and the surgical procedure was associated with greater postoperative pain, but not with greater postoperative bleeding.

Prolonged Opioid Use After Lumbar Fusion Surgery: A Meta-Analysis of Prevalence and Risk Factors.

BACKGROUND: Persistent opioid utilization after spine surgery is a rising complication among both preoperatively opioid-naïve and opioid-tolerant patients. To our knowledge, this is the first meta-analysis to determine the prevalence and characterize the risk factors that predispose patients to prolonged opioid use (≥3 months) after lumbar fusion. METHODS: Studies were identified through searches in PubMed and EMBASE from each database's earliest records to February 1, 2022. We included observational studies examining the risk factors and rates of prolonged opioid use following lumbar fusion. Pooled odds ratios (ORs) or standardized mean differences with corresponding 95% confidence intervals (CI) were estimated using inverse-variance methods. RESULTS: In this meta-analysis of 12 studies encompassing 80,935 patients, 40.2% of patients continued to fill opioid prescriptions ≥3 months after lumbar fusion. Significant sociodemographic predictors included Medicare or Medicaid insurance (OR=1.60, 95% CI 1.36-1.88), African-American ethnicity (OR=1.29, 95% CI 1.18-1.41), being from the Southern United States (OR=1.18, 95% CI 1.11-1.25), or women (OR=1.10, 95% CI 1.01-1.20). Being from the Midwestern United States (OR=0.80, 95% CI 0.75-0.85) was found to be a protective factor. Comorbidities associated with increased risk of prolonged opioid use were preoperative opioid use (OR=5.76, 95% CI 3.52-9.41), drug abuse (OR=3.11, 95% CI 2.37-4.08), alcohol abuse (OR=2.37, 95% CI 2.14-2.64), psychiatric disorders (OR=2.29, 95% CI 1.94-2.70), smoking history (OR=1.81, 95% CI 1.23-2.66), arthritis (OR=1.35, 95% CI 1.29-1.40), and higher American Society of Anesthesiologists score (standardized mean difference=0.72, 95% CI 0.61-0.82). CONCLUSIONS: The high prevalence of prolonged opioid use after lumbar fusion underscores the importance of screening patients for comorbidities and implementing targeted strategies to minimize opioid misuse.

Macrovascular Decompression with the Transposition Method Using Teflon Sling for Trigeminal Neuralgia Caused by the Vertebrobasilar Artery.

OBJECTIVE: Complete separation of the vertebrobasilar artery (VBA) from the trigeminal nerve by microvascular decompression is technically challenging. This paper evaluates the transposition method using Teflon sling for trigeminal neuralgia (TN) caused by the VBA. METHODS: Retrospective review of 32 patients including 2 patients with tic convulsif. Mobilization of the VBA in the anteromedial-caudal direction and repositioning of the VBA using Teflon sling and fibrin glue were performed. Pre- and postoperative pain were evaluated with the Barrow Neurological Institute (BNI) pain intensity score. Duration of surgery and postoperative neurologic complications were reviewed. RESULTS: Preoperative BNI score ranged from III to V. Postoperative BNI score I was observed in 30 patients, II in 1 patient, and V in 1 patient as recurrence. Abducens nerve palsy was observed in 9 patients but was transient in 8. Permanent hearing loss was observed in 6 patients. Transient mild lower cranial nerve palsy was recorded in 2 patients with tic convulsif. Average surgical time was 290 minutes. CONCLUSIONS: Our method for trigeminal neuralgia caused by VBA was very effective, but the complication rate of cranial nerve disorders was also high. A high rate of complications implied the technical difficulty of extensive vascular mobilization requiring long duration of surgery. Macrovascular decompression surgery is more descriptive of this surgery instead of microvascular decompression surgery.

Lidocaine Infusion for the Management of Postoperative Pain and Delirium (LIMPP): protocol for a randomised control trial.

INTRODUCTION: Postoperative delirium is a frequent adverse event following elective non-cardiac surgery. The occurrence of delirium increases the risk of functional impairment, placement to facilities other than home after discharge, cognitive impairment at discharge, as well as in-hospital and possibly long-term mortality. Unfortunately, there is a dearth of effective strategies to minimise the risk from modifiable risk factors, including postoperative pain control and the analgesic regimen. Use of potent opioids, currently the backbone of postoperative pain control, alters cognition and has been associated with an increased risk of postoperative delirium. Literature supports the intraoperative use of lidocaine infusions to decrease postoperative opioid requirements, however, whether the use of postoperative lidocaine infusions is associated with lower opioid requirements and subsequently a reduction in postoperative delirium has not been investigated. METHODS AND ANALYSIS: The Lidocaine Infusion for the Management of Postoperative Pain and Delirium trial is a randomised, double-blinded study of a postoperative 48-hour infusion of lidocaine at 1.33 mg/kg/hour versus placebo in older patients undergoing major reconstructive spinal surgery at the University of California, San Francisco. Our primary outcome is incident delirium measured daily by the Confusion Assessment Method in the first three postoperative days. Secondary outcomes include delirium severity, changes in cognition, pain scores, opioid use, incidence of opioid related side effects and functional benefits including time to discharge and improved recovery from surgery. Lidocaine safety will be assessed with daily screening questionnaires and lidocaine plasma levels. ETHICS AND DISSEMINATION: This study protocol has been approved by the ethics board at the University of California, San Francisco. The results of this study will be published in a peer-review journal and presented at national conferences as poster or oral presentations. Participants wishing to know the results of this study will be contacted directly on data publication. TRIAL REGISTRATION NUMBER: NCT05010148.