Decreasing Perioperative Opiate Use During Pancreaticoduodenectomy Using Transversus Abdominus Plane Blocks: A Review of the Literature.

BACKGROUND: Pancreatoduodenectomy is a highly complex surgical procedure associated with high postoperative morbidity and mortality. Treatment of postoperative pain is crucial to preventing chronic pain and further complications. Opioids are the leading treatment modality for acute postoperative pain for all surgical procedures in the US, contributing to the opioid epidemic, a crisis causing death and lifelong impairment in many patients. Multimodal analgesia techniques, such as the transversus abdominis plane (TAP) block, are suggested to reduce perioperative opioid usage. This exploratory literature review aims to investigate the use of TAP block in postoperative pain and opioid use in patients undergoing pancreatoduodenectomy. MATERIALS AND METHODS: A search strategy developed from Cochrane best practice recommendations was applied to a comprehensive search of PubMed, Scopus, and PsycINFO databases, yielding three articles of relevance in patients having pancreatic surgery. RESULTS: Previous research demonstrates TAP block efficacy in decreasing opiate consumption after major abdominal surgery; however, there is a paucity of data regarding opioid consumption in pancreatoduodenectomy patients. CONCLUSION: Research in relation to TAP block analgesia is varied given the variety of approaches, techniques, and timing of the TAP block procedure. Future research should seek to elucidate the role of TAP blocks in reducing postoperative pain and opioid consumption in pancreatoduodenectomy patients.

Preoperative transversus abdominis plane block decreases intraoperative opiate consumption during minimally invasive cholecystectomy.

BACKGROUND: The ongoing epidemic of prescription opiate abuse is one of the most pressing health issues in the United States today. Consequently, analgesic adjuncts, such as multimodal drug regimens and regional anesthetic blocks (like transversus abdominis plane (TAP) block), have been introduced to the perioperative period in hopes of decreasing postoperative opiate use. However, the effect of these interventions on intraoperative opiate use has not been examined. We hypothesized that preoperative TAP block would be associated with decreased intraoperative opiate use during minimally invasive cholecystectomy. METHODS: This was a retrospective review of patients undergoing minimally invasive cholecystectomy between June 2018 and January 2021. Perioperative data, operative times, and medication administration data were collected. Intraoperative opiate use was calculated in total morphine equivalent doses (MED) for each patient and adjusted for operative time. Univariate analysis and multivariate linear regression were performed to determine factors affecting intraoperative opiate requirements. RESULTS: 261 patients were included in this study, of which 62 (23.8%) received preoperative TAP block and 199 (76.2%) did not. Preoperative TAP block was associated with decreased intraoperative opiate use (0.199 vs 0.312, p < 0.001), while there were no statistically significant differences associated with other analgesic adjuncts including preoperative acetaminophen (p = 0.485), celecoxib (p = 0.112), gabapentin (p = 0.165), or intraoperative ketorolac (p = 0.200). On multivariate analysis, preoperative TAP block was independently associated with decreased intraoperative opiate use (< 0.001), while chronic cholecystitis on final pathology was associated with increased intraoperative opiate use (p = 0.002). CONCLUSION: The use of preoperative TAP block was associated with decreased intraoperative opiate use during minimally invasive cholecystectomy and should be considered for routine use. Future research should investigate whether preoperative TAP blocks and a subsequent decrease of intraoperative opiates, also result in a decrease in postoperative opiate use and improvements in postoperative outcomes.

Preoperative transversus abdominis plane block decreases intraoperative opiate use during pancreatoduodenectomy.

BACKGROUND: Multimodal analgesia and regional anesthetic blocks, such as transversus abdominis plane (TAP) block, decrease postoperative opiate consumption but their effect on intraoperative opiates is unknown. METHODS: This was a retrospective review of patients undergoing pancreatoduodenectomy between June 2018 and February 2021, in which perioperative data, operative times, and medication administration data were collected. Intraoperative opiate use was calculated in total morphine equivalent doses (MED) for each patient and adjusted for operative time. Univariate analysis and multivariate linear regression were performed to determine factors affecting intraoperative opiate requirements. RESULTS: Of the 169 patients in the study, 51 (30.2%) received pre-surgical TAP blocks and 118 (69.8%) did not. There were no statistically significant differences in intraoperative opiate use with preoperative acetaminophen (p = 0.527), celecoxib (p = 0.553), gabapentin (p = 0.308), intraoperative ketorolac (p = 0.698) or epidural placement (p = 0.086). Minimally invasive surgery had lower intraoperative opiate use compared to open (p = 0.011), as well as pre-surgical TAP block compared to no pre-surgical block (5.24 vs 7.27 MED/hour, p < 0.001). On multivariate linear regression, pre-surgical TAP block (p = 0.001) was independently associated with decreased intraoperative opiate use. CONCLUSION: Preoperative TAP blocks were associated with decreased intraoperative opiate use during pancreatoduodenectomy and should be considered for routine use.

Effect of perioperative cognitive behavioural therapy on chronic post-surgical pain among breast cancer patients with high pain catastrophising characteristics: protocol for a double-blinded randomised controlled trial.

BACKGROUND: Surgery is regarded as the primary treatment for breast cancer. Chronic post-surgical pain (CPSP) is a recognised complication after breast cancer surgery, and it is estimated to affect 20-30% of women. Pain catastrophizing has emerged as one of the most influential psychological variables associated with CPSP. METHODS: This trial will be a single-centre, prospective, double-blinded, superiority, randomised controlled trial (RCT). Patients scheduled for elective breast cancer surgery (wide local excision or mastectomy with or without axillary lymph node dissection) will be screened preoperatively for high pain catastrophising. Patients with high pain catastrophising, defined as a score of ≥ 24 on the Pain Catastrophising Scale will be deemed eligible for inclusion in the study. Participants will be randomly assigned to receive either a cognitive behavioural therapy or an educational mindfulness based programme during their perioperative period. The primary outcome is the Brief Pain Inventory short form average pain severity score at 3 months postoperatively. Secondary outcomes include patient-reported quality of recovery at days 1-2 after surgery, levels of pain catastrophising, reported depressed mood and anxiety. DISCUSSION: To the best of our knowledge, this protocol describes the first RCT which directly examines the effect of perioperative cognitive behavioural therapy on CPSP among breast cancer patients with high pain catastrophising characteristics. The outcomes of this trial may have significant implications for these patients because perioperative cognitive behavioural therapy has the potential to become an important perioperative intervention to complement patient management. TRIAL REGISTRATION: ClinicalTrials.gov NCT04924010 . Registered on 11 June 2021. All item from the World Health Organisation Trial Registration Data set have been included.

Peer review for the Canadian Journal of Anesthesia in 2016 and 2017: a retrospective analysis by reviewer and author gender.

PURPOSE: Our objectives were to analyze the gender of reviewers of all manuscripts submitted to the Canadian Journal of Anesthesia in 2016 and 2017. We hypothesized that the percentage of reviewers who were women would be ≤ 25%, an estimate based on the expert opinion estimates of the investigators and much less than the overall proportion of women in medicine. METHODS: Reviewers and authors of manuscripts submitted between 1 January 2016 and 31 December 2017 were coded as "woman", "man", or "unknown gender" according to an internet search of the person's name, address, medical registration, and/or first name. We also explored associations between reviewer gender and author gender, numbers and types of manuscripts assigned, as well as speed of acceptance and completion of reviews. RESULTS: Of the 1,300 manuscripts for which first and corresponding author gender were identified, 855 manuscripts (66%) were only assessed internally by the editor-in-chief and/or associate editors, and 445 manuscripts (34%) were sent for external peer review. Of the 280 reviewers for these manuscripts, 64 (22.9%; 95% confidence interval [CI], 18.3 to 28.1) were women (P = 0.40 compared with 25%). Women provided 174 (18%) and men provided 780 (82%) of the 954 external written reviews. Four hundred and seventy of the 1,300 manuscripts (36.2%; 95% CI, 33.6 to 38.8) had a woman as the first and/or corresponding author. CONCLUSIONS: Despite 36.2% of the authors being women, only 22.9% of reviewers were women and they represented only 18% of the individual written reviews gathered. Our results are consistent with previous reports of underrepresentation of women as reviewers in various disciplines. Formal policies that promote increased gender diversity should be considered.

Severe acute pain and persistent post-surgical pain in orthopaedic trauma patients: a cohort study.

BACKGROUND: We conducted a cohort study of adult patients presenting for orthopaedic trauma surgery at a statewide trauma centre, with the aims of determining (i) the incidence and risk factors for severe acute pain in the PACU, and (ii) the incidence and risk factors for persistent post-surgical pain at 3 months. METHODS: Data were collected before operation, in the PACU, 72 h after surgery and 3 months after surgery, and included numerical rating scale (NRS) scores for pain, and modified Brief Pain Inventory-Short Form, Kessler Psychological Distress Scale, World Health Organization Disability Assessment Schedule, and Pain Catastrophizing Scale scores. RESULTS: Severe acute pain in the PACU was reported by 171 (56%; 95% confidence interval [CI]: 51%, 62%) of the 303 included patients. Female sex (odds ratio [OR]: 1.86; 95% CI: 1.06, 3.26) and prior post-injury surgery (OR: 2.21; 95% CI: 1.11, 4.41) remained associated with severe acute pain after multivariable adjustment. Persistent post-surgical pain at 3 months was reported by 149 (65%; 95% CI: 59%, 71%) of the 229 included patients. The preoperative NRS score (OR: 1.17; 95% CI: 1.03, 1.32) remained associated with persistent pain after multivariable adjustment. CONCLUSIONS: We identified three easy-to-measure risk factors: female sex, prior post-injury surgery for severe acute pain, and preoperative NRS scores for persistent pain. Further research is required to identify pain management strategies and psychosocial interventions to reduce the burden of pain, disability, and distress in these patients.