Continuous epidural infusion of morphine for treatment of pain after thoracic surgery: a new technique.

We evaluated postoperative pain relief and the incidence of side effects of three methods of thoracic epidural analgesia. Ninety patients, divided into three equal groups, received postoperative analgesia after thoracic surgery either as intermittent epidural injections of bupivacaine (25 mg/5 ml, 0.5% solution) as needed, or, intermittent epidural injections of morphine (5 mg/5 ml of normal saline, 0.1% solution) as needed, or continuous epidural infusion of morphine (0.1 mg, in 1 ml of normal saline) per hour supplemented with intravenous morphine (2 mg) upon request. pain relief was evaluated by each patient on a pain scale visual analogue and by pain relief questionnaire for a period of 72 hr. Postoperative pain relief was achieved equally with these three methods of epidural analgesia in all patients with no significant difference between groups. Intermittent epidural injection of bupivacaine relieved pain for 4.9 +/- 1.9 (SD) hr/injection and was associated with urinary retention in all patients, with numbness and weakness of the hands in 12 patients, and with severe hypotension in 7 patients. Intermittent epidural injection of morphine relieved pain for 5.8 +/- 2.3 hr/injection and was associated with urinary retention in all patients, with pruritus in 12 patients, and with central narcosis and respiratory depression in 8 patients. Continuous epidural infusion of morphine with occasional intravenous morphine (2 mg) supplementation also effectively relieved postoperative pain and was associated with minimal systemic side effects. One patient complained of pruritus, and two patients developed urinary retention.(ABSTRACT TRUNCATED AT 250 WORDS)

Palliative radiotherapy for bone pain in hormone refractory prostate cancer

From 1970 to 1992, 23 patients were treated with irradiation for palliation of pain caused by bone metastases from hormone refractory adenocarcinoma of the prostate at Cancer Institute Hospital. External beam irradiation was delivered to painful bony metastatic sites using linear accelerator. Numbers of irradiated sites were 1, 2, 3 in 6 patients, 4 in 3 patients and 5 or 7 in one patient. To evaluate the pain relief at the irradiated sites, severity and frequency of pain were measured quantitatively before and 1 month after the treatment. Overall efficacy of palliation was evaluated by summing up results of the irradiated sites in each patient. pain relief was obtained in all the irradiated sites. Minimal relief, partial relief and complete relief of pain were achieved in 10%, 15% and 75% of the 60 irradiated sites, respectively. No significant dose-response relationship was observed. Complete pain relief was attained less frequently at the sites with severe and constant pain that those with moderate and intermittent pain. Minimal, partial and complete palliation of pain was attained in 9%, 17% and 74% of 23 patients, respectively. In patients with highly extensive bone metastases, many irradiated sites, or many irradiated bones, complete palliation was difficult to obtain. Recurrence of pain was observed in one site. In other 59 irradiated sites, pain relief lasted until patient's death or throughout the follow-up period (maximum 51 months, median 9 months). We concluded that external beam irradiation is an effective palliation therapy for pain of bone metastases from hormone refractory prostate cancer and will play a considerable role in the management of advanced disease.

Percutaneous alcoholization of the celiac plexus under echographic guidance: an alternative to splanchnicectomy? Study of 21 cases

Celiac plexus block is usually performed under fluoroscopic or tomodensitometric guidance. We report on a new procedure using sonographic guidance. The patient lies in supine position. We use a real-time sonograph (Kontron Sigma 1 AC) with a 3.5 MHz probe. On a transverse plane, the celiac axis is localized emerging from aorta. After local anesthesia, the tip of the spinal needle (177 mm, 22 G) is placed close to aorta (about 5 mm) on both sides. 10 to 15 ml of 1 per cent lidocaine then 10 to 15 ml of absolute alcohol are injected on each side. 21 patients (10 males, 11 females, mean age: 61) underwent the procedure. They presented with cancer of the pancreas in 14 cases, metastatic nodes in 3 cases, cholangiocarcinoma in 2 cases and chronic calcifying pancreatitis (CCP) in 2 cases. No pain relief occurred in 3 patients (14 per cent). On of those presented with CCP but the endoscopic cystic diversion of a small cyst was successful to eradicate pain. Partial pain relief occurred in 5 cases (24 per cent). Total pain relief was obtained in 13 cases (62 per cent). No complication related to the treatment was observed. Sonography is a simple and safe method of guidance to perform alcohol block of the celiac plexus. The anterior approach may prevent neurologic complications related to other methods of guidance.

Impact of laparoscopic surgery in the treatment of chronic abdominal pain syndrome

Chronic abdominal pain syndrome is becoming increasingly important with regard to the quality of life of the patients and its social and economic impact, in terms of cost of hospitalization, income loss due to sick leave, and pharmaceutical costs for treatments which fail to offer either significant clinical improvement or resolution of the pain symptoms. The main symptom is chronic abdominal pain, which may vary in intensity and may be associated with constipation and episodes of vomiting, when the clinical picture evolves toward one of subocclusion or total occlusion of the bowel. We considered the following criteria in our selection of patients for this study: 1) quality of life, 2) constant use of antispastic and analgesic medications, 3) absence of any other diagnosticable pathology prior to the operation. From August 1992 to April 2000 we operated on 105 patients with this syndrome (16 males and 89 females). Among these 8 patients had never been subjected to a laparotomy, while 97 had previously undergone surgical procedures (126 laparotomies). In the first 85 patients in the series (81%) we used a 10 mm laparoscope (0-30 degrees) to evaluate the presence of abdominal-visceral adhesions based on the type of surgery the patient had undergone previously, as well as the location of the pain reported by the patient. In 41 cases (48.2%) the pneumoperitoneum was obtained with the Veress needle. In another 44 cases (51.8%) the Hasson technique was used. Since June 1999, we have carried out the exploration of the abdominal cavity in 20 patients (19%) using a trocar and 2.2 mm laparoscope in the left hypochondrium along with a mini-trocar placed either in the right or left flank. (The positioning of the trocars depended on the previous surgical procedures performed). The exploration included inspection of the abdominal cavity. In 8 of the patients the procedure was carried out under local anaesthesia We performed laparoscopic adhesiolysis in 93 cases; in 7 cases no signs of adhesions were seen, while in another 5 cases it was necessary to convert the original laparoscopic procedure to a laparotomy. The types of adhesions found were fine-filmy (46%), dense-vascularised (46%), and cohesive (16%). In 6 cases during lysis of the adhesions complications of serous-muscular lesions occurred, which required laparotomic repair. In 5 cases we diagnosed a pathological condition which was not suspected. The average postoperative hospital stay was 2 days (range: 1-7); no major postoperative complications were noted. In the course of the follow-up of 78 patients over an average of 37 months (range: 6-72) the results obtained were as follows; 47 patients (60.2%) had complete pain relief, 18 patients (23.1%) had partial pain relief, and the remaining 13 patients (16.7%) had no significant pain relief. Laparoscopic exploration in patients with chronic abdominal pain is technically feasible in a simple manner in most patients. By means of careful and accurate preoperative selection of the patients partial if not complete pain relief can be achieved in a high percentage of cases (83.3% in our series).

Multi-fractionated wide-field radiation therapy for palliation of multiple symptomatic bone metastases from solid tumors.

PURPOSE: This was a pilot study to explore the toxicity and response of multi-fractionated wide-field radiation therapy (MF-WFRT) in patients with multiple symptomatic osseous metastases. PATIENTS AND METHODS: From February 1997 to April 1998, a total of nine patients (5 lung cancer, 3 breast cancer, 1 prostate cancer) were treated with MF-WFRT. The patients received 1.5 Gy per fraction (twice a day) to a total dose of 7 Gy in 3 days for the upper body and a total dose of 9 Gy in 3 days for the lower body. Ten treatments in nine patients were carried out with this technique (2 upper half-body, 5 lower half-body, 3 mid-body; one patient had both upper mid-body and lower-half body treatments). RESULTS: pain relief was complete in two patients (20%) and eight (80%) achieved better than 50% pain relief. Seventy-five percent of pain responders achieved pain relief within one week of MF-WFRT. The pain relief was long-lasting and continued without need of reirradiation for 45% of the remainder of the patients' lives. The incidence of gastrointestinal complications was low, basically Grade 1-2 toxicity. Four patients (40%) experienced Grade 3-4 hematological toxicity. Hematological toxicity was treated with blood transfusion or G-CSF. General tolerance was excellent, and no pneumonitis or radiation-related deaths occurred. CONCLUSION: This treatment modality appears to be well tolerated and effective. The optimal indications, dose, and fractionation for MF-WFRT should be further explored in randomized studies.

Long term results of pancreaticojejunostomy in chronic pancreatitis.

Fifty-one consecutive pancreaticojejunostomies for pain in chronic pancreatitis performed during the years 1964 to 1983 have been reviewed. Mean observation time was 8.2 years. Information on alcohol consumption, pain intensity and clinical signs of pancreatic dysfunction was recorded at regular intervals. Operative mortality was nil. Analysis showed no difference between alcohol abusers and other patients with regard to calcification, ductal dilation or exocrine and endocrine insufficiency. Good to excellent pain relief was achieved in 65 per cent of abusers and 88 per cent of nonabusers and was stable for at least five years. Patients who are heavy and unremitting abusers did not get much pain relief as a result of the operation. Patency of the anastomosis does not seem to be crucial for pain relief after pancreaticojejunostomy.

Dose-dependent epidural leakage of polymethylmethacrylate after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures.

OBJECT: The use of polymethylmethacrylate (PMMA) cement by percutaneous injection in cases requiring vertebroplasty provides pain relief in the treatment of osteoporotic vertebral compression fractures. A retrospective study was performed to assess what caused PMMA cement to leak into the epidural space and to determine if this leakage caused any changes in its therapeutic benefits. METHODS: Polymethylmethacrylate was injected into 347 vertebral compression fractures in 159 patients. The cement leaked into the epidural space in 92 (26.5%) of 347 treated vertebrae in 64 (40.3%) of the 159 patients, as demonstrated on postoperative computerized tomography scanning. Epidural leakage of PMMA cement occurred more often when injected above the level of T-7 (p = 0.001) than below. The larger the volume of PMMA injected the higher the incidence of epidural leakage (p = 0.03). Using an injector also increased epidural leakage (p = 0.045). The position of the needle tip within the vertebral body and the pattern of venous drainage did not affect epidural leakage of the cement. Leakage of PMMA into the epidural space reduced the pain relief expected after vertebroplasty. The immediate postoperative visual analog scale scores were higher (and therefore reflective of less pain relief) in patients in whom epidural PMMA leakage occurred (p = 0.009). Three months postoperatively, the authors found the highest number of patients presenting with pain relief, including those in the group with epidural leakage, and at this follow-up stage there were no significant differences between the two groups. CONCLUSIONS: The authors found that epidural leakage of PMMA after percutaneous vertebroplasty was dose dependent. The larger amount of injected PMMA, the higher the incidence of leakage. Injecting vertebral levels above T-7 also increased the incidence of epidural leakage. Epidural leakage of PMMA may attenuate only the immediate therapeutic effects of vertebroplasty.

Microsurgical DREZotomy for pain of spinal cord and Cauda equina injury origin: clinical characteristics of pain and implications for surgery in a series of 26 patients.

The result of the DREZotomy procedure used for the treatment of chronic intractable neuropathic pain caused by injuries at the T9-L4 spine level in 26 patients has been reported. For the purpose of identifying the most favorable pain pattern for DREZ surgery we retrospectively analyzed the effectiveness of surgical treatment on different forms of pain in the follow-up period of 13-50 months, 37 months on average. All pain forms were classified according to subjective sensory pain expression including the rhythm and topography of the pain. Three groups of pain were formed according to subjective sensory equivalents: pain of thermal quality (burning, boiling, baking, warm etc.), pain of mechanical-nonthermal quality (shooting, cutting, stabbing, sharp, incisive, cramping, constriction, distraction, throbbing etc.). The third group was the combination of the previous two. Success in pain relief has been defined as a 50% or greater reduction in pain after surgery such that pain no longer interferes with patient activities of daily living and sleeping pattern and no longer requires routine analgesic pain medication. Our results revealed that the pain of mechanical-nonthermal nature and intermittent rhythm, confined to segmental topography was the most responsive to the DREZ surgical treatment so that 90% patients suffering from this pain pattern experienced a good long-term pain relief (70% had complete long term pain relief). Neuropathic pain of thermal quality with the diffuse infralesional distribution and steady rhythm was the most resistant to the DREZ surgical treatment: neither patient had long-term relief of this pain pattern. In the group of patients suffering from pain consisting of combined mechanical and thermal sensory components with confined pain territory, 75% experienced a good long-term pain relief (50% had complete long-term pain relief). Immediate pain relief was obtained in 88% of patients and was long lasting in 69% of the total series. Our results pointed to confined territory, intermittent rhythm and mechanical nature of the pain as the most relevant predictors of the expected pain relief achieved by the DREZ surgery.

Long-term results by epidural spinal electrical stimulation (ESES) in patients with inoperable severe lower limb ischaemia.

Arterial reconstruction is the treatment of choice for patients with severe lower limb ischaemia, but may at times be technically impossible. Thirty-two consecutive patients with impending (n = 24) or already established (n = 8) distal arteriosclerotic or diabetic lower limb gangrene, in whom vascular surgery was either technically impossible or had failed, were treated with epidural spinal electrical stimulation (ESES) for 27 +/- 16 (S.D.) months. All patients had severe rest pain, which was reduced by ESES in 91% of the cases. Improved ulcer healing was noted in 58% of the patients who had skin ulceration. Eighty-three percent of those patients who did not have established gangrene when ESES was started, retained their leg after 1 year, and 54% after 3 years. These results suggest that ESES often provides pain relief and improves skin healing in patients with impending arteriosclerotic or diabetic gangrene in whom vascular surgery is impossible or has failed. Epidural spinal electrical stimulation (ESES) does not affect the progression of established gangrene but may provide pain relief. The observed outcome of severe limb ischaemia in this study could be used to compare with those after arterial reconstruction performed in patients with poor run-off vessels, and may allow us to examine the natural history of this disease when adequate pain relief is provided. The results reported here and the previously reported enhancement of cutaneous blood flow in severely ischaemic extremities by ESES may suggest, that ESES enhances limb salvage by improving skin blood flow.

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.