Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

The Long-term Effectiveness of Sacral Neuromodulation in Treating Low Anterior Resection Syndrome: A Single Center Experience

Abstract Background Sacral neuromodulation (SNM) has emerged as an effective treatment option for patients with fecal incontinence. The efficacy of SNM in the treatment of low anterior resection syndrome (LARS) following rectal cancer surgery is encouraging. The aim of this study is to review the long-term outcomes of patients treated with SNM for LARS. Methods A review of a prospectively maintained database of consecutive SNM procedures for LARS between June 2017 and June 2020 was conducted. Bowel habits diaries, the Cleveland Clinic Florida-Fecal Incontinence score (CCF-FIS), the Fecal Incontinence Quality of Life Scale (FIQoL), and the LARS score were evaluated at baseline, three months, and twenty-four months after definitive SNM implantation. Results The study included 14 patients; 11 of them were males, and the mean age was 59.2 (±10.2). Thirteen patients underwent permanent implantation of the SNM device. The mean score of FI episodes were reduced from 16 to 4 (p &lt; 0.001) and the mean CCF-FIS dropped from 15.2 to 6.5 (p &lt; 0.001). All patients showed a substantial increase in their FIQoL scale (p &lt; 0.001). Additionally, there was a significant amelioration in the LARS score (36.7 to 17.3, p &lt; 0.001) and all symptoms of LARS except incontinence of liquid stool (p = 0.97). Conclusions SNM improves bowel dysfunction and quality of life in patients with LARS following rectal cancer surgery and maintains its effectiveness over time</jats:p

Neglected prognostic importance of ileal resection in patients with peritoneal metastasis

Abstract Background We aimed to determine the prognostic role of ileal resection on postoperative complications and the final oncological results of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) treatment in patients with peritoneal metastasis(PM). Methods Patients with PM who underwent CRS and HIPEC between 2007 and 2020 were analyzed retrospectively. Ileal resection was defined as the resection of the ileum at 100 cm or below. Patients were divided into ileal-resection and non-ileal resection groups. Besides clinico-pathological variables, peritoneal cancer index (PCI), completeness of cytoreduction (CC-0-1-2), (neo)adjuvant chemotherapy, operative time, need for surgical intensive care unit, and usage of blood products were all evaluated. Results The data of 664 patients was analyzed. Ileal resection was performed in 346(52.1%) patients. The median follow-up period was 27 months. The ileal resection group had significantly lower 3-and 5-year survival rates (55% and 43% vs. 69% and 52, p = .005, respectively). High PCI score (p &lt; .001), more CC-1-2 cytoreductions (p &lt; .001), more anastomoses (p &lt; .001), prolonged operative time (p &lt; .001), more ostomy creation (p = .001), increased morbidity (p &lt; .001), and more infectious complications (p &lt; .001) were all significantly associated with ileal resection. Conclusion The loss of ileal function has a potential prognostic role in increased post-operative complications and worsened overall survival in patients with PMs.</jats:p

Report of a rare case: Double recurrent laryngeal nerve

One of the most important and feared complications of thyroid and parathyroid surgery is injury to the recurrent laryngeal nerve. The main reason for this type of injury is anatomical variations. Currently, nerve monitoring is being widely used to reduce complications due to the high variation rate. However, it is not being used extensively in our country, due to cost related issues. In this case, we present a left sided double recurrent laryngeal nerve

Should Alvarado and Ohmann scores be real indicators for diagnosis of appendicitis and severity of inflammation?

BACKGROUND: Acute appendicitis is one of the most common causes of abdominal pain seen in surgical clinics. Although it can be easily diagnosed, the picture may be confusing, particularly in premenopausal women and the elderly. The present study is an evaluation of 2 of the current scoring systems with respect to accurate diagnosis of the disease and indication of inflammation severity

Inflammation-based prognostic scores in geriatric patients with rectal cancer.

Background Morbidity/mortality and oncologic outcomes can be worsened in geriatric rectal cancer patients due to comorbidities and frailty. The aim of this study was to compare surgical and oncological results of geriatric rectal cancer patients using inflammation-based prognostic scores. Methods The prospectively maintained database of 991 rectal cancer patients treated at our center between 2007 and 2020 were analyzed. All conventional clinicopathologic features, and oncologic outcomes are compared between patients >= 65 years old (geriatric patients: Group I) and = 65 years old (Group I; 349 males, median age 74 [range 65-9]) years) and 424 (42.8%) who were < 65 years old (Group II; 252 males, median age 58 [range 20-64] years). The high-grade [Clavien-Dindo III-IV] complications rates of Group I and Group II patients sere 20% (n = 113), and 9% (n = 37), respectively. High-grade complications were related to mGPS (p < 0.001) and CAR (p < 0.001) values. The high-grade complication rate was found to be higher in Group I than in Group II, and this was statistically significant (p < 0.001). High preoperative mGPS and CAR values were significantly associated with postoperative mortality (p < 0.001). In Cox multivariate analysis, mGPS (p = 0.003) and CAR (p = 0.001) were significantly in correlation with lowered overall survival. The mGPS and CAR were found to be independent prognostic factors for overall survival. Conclusions The mGPS and CAR can predict severe postoperative complications and early mortality. mGPS, and CAR have a powerful prognostic value and the potential clinical usefulness to predict decreased overall survival in both geriatric and non-geriatric rectal cancer patients