Effect of Radiofrequency Thermocoagulation of Thoracic Nerve Roots in Patients with Cancer and Intractable Chest Wall Pain.

BACKGROUND: Interventional pain management is essential for patients with cancer who experience medically uncontrollable chest wall pain to help control their symptoms and improve their quality of life. However, there is a lack of data on this topic, so there is an urgent need for further research. OBJECTIVES: To identify the effects of radiofrequency ablation (RFA) of the thoracic nerve roots on pain outcomes in patients with cancer and intractable chest wall pain. STUDY DESIGN: Retrospective, observational cohort study. SETTING: National Cancer Center in Korea. METHODS: The medical records of patients with cancer who were referred to the pain clinic at our National Cancer Center for intractable chest wall pain and who underwent thoracic nerve root RFA between Jan. 1, 2011 and Dec. 31, 2015 were analyzed. The primary outcome was the change in Numeric Rating Scale (NRS) scores between pre-procedure and one week, one month, and 6 months post-procedure. The secondary outcomes were the change in morphine equivalent daily dose (MEDD) between pre-procedure and one week, one month, and 6 months post-procedure, and whether the primary cancer type (lung vs. non-lung) or radiotherapy to the chest within one month affected the outcomes of RFA. The Wilcoxon signed-rank test was used to compare RFA data between pre and post-procedure and P values less than 0.05 were considered statistically significant. RESULTS: One hundred patients were included in the final analysis. The median NRS score in patients who underwent RFA decreased from 7 (range 3-10) pre-procedure to 4 (0-9) at one week and one-month post-procedure (both P < 0.001) and 4 (1-8) at 6 months post-procedure (P < 0.001). The median MEDD value decreased from 200 (range 30-1800) mg pre-procedure to 180 (10-1600) mg at one week post-procedure (P < 0.001), but there was no statistically significant change at one month (P = 0.699) or 6 months (P = 0.151) post-procedure. There was no difference in RFA outcome according to type of primary cancer or radiotherapy to the chest within one month. LIMITATIONS: Retrospective design. CONCLUSION: Radiofrequency thermocoagulation of the thoracic nerve roots achieved effective short-term pain control in patients with cancer and intractable chest wall pain. KEY WORDS: Radiofrequency ablation, thermocoagulation, thoracic nerve root, cancer, chest wall pain, radiotherapy, pain relief.

The Effect of Chronic Opioid Use on End-Tidal Concentration of Sevoflurane Necessary to Maintain a Bispectral Index Below 50: A Prospective, Single-Blind Study.

BACKGROUND: Opioid analgesics decrease the minimum alveolar concentration of inhalation agents during the acute phase response. However, the effect of chronic opioid exposure on minimum alveolar concentration of inhalation agents remains unknown. This study aimed to determine the concentration of sevoflurane necessary to maintain a bispectral index (BIS) <50 (SEVOBIS50) in patients with chronic opioid use compared with those naïve to opioid use. METHODS: We included chronic opioid users who received a stable dose of oral morphine of at least 60 mg/d according to the morphine equivalent daily dose for at least 4 weeks and opioid-naïve patients. General anesthesia that included thiopental, vecuronium, and sevoflurane in oxygen was administered to all patients. Anesthesia was maintained using predetermined end-tidal sevoflurane concentrations. Fifteen minutes after achieving the determined end-tidal sevoflurane concentration through closed circuit anesthesia, BIS was measured for 1 minute in both groups. SEVOBIS50 was determined using Dixon's up-down method and probit analysis. RESULTS: Nineteen and 18 patients from the chronic opioid and control groups, respectively, were included in the final analysis. SEVOBIS50values for the chronic opioid and control patients were 0.84 (95% confidence interval, 0.58-1.11) and 1.18 (95% confidence interval, 0.96-1.40), respectively (P = .0346). CONCLUSIONS: Our results suggest that the end-tidal concentration of sevoflurane necessary to maintain a BIS <50 is lower for chronic opioid users than for opioid-naïve patients.

Impact of Celiac Plexus Neurolysis on Survival in Patients with Unresectable Pancreatic Cancer: A Retrospective, Propensity Score Matching Analysis.

BACKGROUND: Pain caused by pancreatic cancer (PC) is difficult to control. Celiac plexus neurolysis (CPN) can effectively control the pain and reduce the use of opioids. However, the effect of CPN on survival for patients with unresectable PC remains controversial. OBJECTIVES: To determine if CPN is associated with survival benefits for these patients. STUDY DESIGN: Retrospective, observational cohort study. SETTING: National Cancer Center in Korea. METHODS: The CPN group included patients who were diagnosed with unresectable PC and underwent fluoroscopically guided bilateral CPN (10 mL dehydrated alcohol each side) once between January 1, 2006, and December 31, 2013. Patients with PC who did not undergo CPN were in the control group; for the final control group, 1:1 propensity score (PS) matching was conducted with the CPN group. The main outcome was median survival (PC diagnosis to death) after PS matching, assessed using Kaplan-Meier curves. RESULTS: For the primary overall survival analysis, the CPN and control groups included 110 and 258 patients, respectively. The median survival period was not significantly different between the CPN and control groups (278 vs. 203 days, P = 0.246), even after PS matching (278 vs. 180 days, P = 0.127), or based on time to CPN from diagnosis (≤ 6 vs. > 6 months; 255 vs. 310 days, P = 0.147). LIMITATIONS: Retrospective design, small sample size, and inconsistent timing of CPN after the diagnosis date. CONCLUSION: CPN did not affect survival for patients with unresectable PC. Considering the limitations of the retrospective design, a well-designed prospective design study should be conducted.Key words: Celiac plexus, pancreatic neoplasms, survival, neurolysis, pain, propensity score matching, opioids, cancer.

Effects of preoperative ultrasound-guided transversus abdominis plane block on pain after laparoscopic surgery for colorectal cancer: a double-blind randomized controlled trial.

BACKGROUND: Although laparoscopic colorectal surgery decreases postoperative pain and facilitates a speedier recovery compared with laparotomy, postoperative pain at trocar insertion sites remains a clinical concern. The objective of this study was to assess the effects of a preoperative ultrasound-guided transversus abdominis plane (TAP) block on pain after laparoscopic surgery for colorectal cancer. METHODS: In total, 58 patients scheduled to undergo laparoscopic surgery following a diagnosis of colorectal cancer were included in this study. The patients were randomized into TAP and control groups; the TAP group patients received a preoperative ultrasound-guided bilateral TAP block with 0.5 mL/kg of 0.25 % bupivacaine, while the control patients received the block with an equal amount of saline. Pain on coughing and at rest was assessed during postanesthetic recovery (PAR; 1 h after surgery) and on postoperative days (PODs) 1 (24 h), 2 (48 h), and 3 (72 h) by an investigator blinded to group allocations using the numeric rating scale (NRS). The primary outcome was pain on coughing on postoperative day (POD) 1. RESULTS: Fifty-five patients were included in the final analysis, including 28 in the TAP and 27 in the control groups. The pain intensity on coughing and at rest during PAR and on PODs 1, 2, and 3 showed no significant differences between groups. Furthermore, there was no significant difference in postoperative opioid consumption, sedation scores, nausea scores at the four time points, complication rates, and length of hospital stay between groups. CONCLUSIONS: In colorectal cancer patients undergoing laparoscopic colorectal surgery, a TAP block did not offer enough benefit for clinical efficacy in terms of postoperative pain or analgesic consumption.

Anesthetic management for a patient with severe mento-sternal contracture: difficult airway and scarce venous access -A case report-.

There are many problems in the anesthetic management of patients with scar contracture. In this case, a 41-year-old male with severe scar contracture on his face, neck, anterior chest, and both shoulders underwent surgery for resurfacing with flaps. We tried to awake fiberoptic orotracheal intubation with GlideScope® Video laryngoscope guide after surgical release of contracture under local anesthesia. We report a successful management of a patient with severe burn contracture achieved by combined effort of surgeons and anesthesiologists.

Acute cholecystitis developed immediately after thoracic kyphoplasty -A case report-.

Postoperative acute cholecystitis is a rare complication of orthopaedic surgery and is unrelated to the biliary tract. In particular, in the case of immediate postoperative state after surgery such as kyphoplasty at the thoracic vertebra, symptoms related to inflammation mimic those of abdominal origin, so the diagnosis and the treatment of acute cholecystitis can be delayed leading to a fatal outcome. It is important that physicians should be aware of the postoperative patient's condition in order to make an early diagnosis and determine treatment.