A prospective investigation of pain and fatigue following pelvic exenteration

Patient Experiences of Long-term Pain and Pain Management Following Pelvic Exenteration for Locally Recurrent Rectal Cancer: A Qualitative Study

BACKGROUND

While pain may persist for patients who undergo pelvic exenteration for treatment of locally recurrent rectal cancer, studies exploring patient experience of postoperative pain and its management remain limited.

OBJECTIVE

This study aimed to explore patient experiences of postoperative chronic pain and management after pelvic exenteration.

DESIGN

Qualitative cohort study of patients who have undergone pelvic exenteration for locally recurrent rectal cancer.

SETTINGS

The study was conducted through one-to-one semi-structured telephone interviews.

PATIENTS

Seventeen patients with locally recurrent rectal cancer who underwent pelvic exenteration between January 2018 and December 2020 were included.

MAIN OUTCOME MEASURES

Semi-structured interviews explored participants' experiences of pain, including its impact on life and management strategies, at 6 and 12 months after exenteration. Interview transcripts were analyzed by two researchers using inductive thematic analysis.

RESULTS

Participant experiences of pain after exenteration are reflected by three identified themes: 1) adapting to long-term consequences of pelvic exenteration, including pain; 2) reluctance to take pain medications; and 3) engaging a multidisciplinary care team is essential to post-pelvic exenteration chronic pain management. Several participants reported ongoing intermittent pain after surgery that significantly affected various aspects of their lives. This prompted participants to adapt their lifestyles and explore alternative pain relief methods because some were hesitant to rely on analgesics.

LIMITATIONS

The small sample size from a single center, whereby all patients underwent curative pelvic exenteration for lower recurrent rectal cancer, with none undergoing the procedure for palliation, limits the generalizability of the results of this study.

CONCLUSIONS

Although chronic pain after pelvic exenteration for locally recurrent rectal cancer interferes with patient's postoperative quality of life, analgesia use was influenced by pain habituation and fear of dependence on pain medications. Our findings emphasize the need to further investigate a multidisciplinary approach, including nonpharmacological methods, for optimization of pain outcomes after pelvic exenteration. See Video Abstract .

EXPERIENCIAS DE PACIENTES SOBRE EL DOLOR A LARGO PLAZO Y SU MANEJO TRAS LA EXENTERACIN PLVICA POR CNCER RECTAL CON RECIDIVA LOCAL UN ESTUDIO CUALITATIVO

ANTECEDENTES:Aunque el dolor puede persistir en los pacientes que se someten a una exanteración pélvica para el tratamiento del cáncer rectal localmente recurrente, los estudios que exploran la experiencia del paciente con el dolor post operatorio y su manejo siguen siendo limitados.OBJETIVO:Este estudio tuvo como objetivo explorar las experiencias de los pacientes con el dolor crónico post operatorio y el manejo después de la exanteración pélvica.DISEÑO:Estudio de cohorte cualitativo de pacientes que se han sometido a una exanteración pélvica para el cáncer rectal localmente recurrente.ESCENARIO:El estudio se realizó a través de entrevistas telefónicas semiestructuradas individuales.PACIENTES:Se incluyeron diecisiete pacientes con cáncer rectal localmente recurrente que se sometieron a una exanteración pélvica entre enero de 2018 y diciembre de 2020.PRINCIPALES MEDIDAS DE RESULTADOS:Las entrevistas semiestructuradas exploraron las experiencias de los participantes con el dolor, incluido su impacto en la vida y las estrategias de manejo a los seis y doce meses después de la exanteración. Las transcripciones de las entrevistas fueron analizadas por dos investigadores utilizando un análisis temático inductivo.RESULTADOS:Las experiencias de dolor de los participantes después de la exanteración se reflejan en tres temas identificados: 1) adaptación a las consecuencias a largo plazo de la exanteración pélvica, incluido el dolor; 2) renuencia a tomar analgésicos; 3) la participación de un equipo de atención multidisciplinario es esencial para el manejo del dolor crónico posterior a la exanteración pélvica. Varios participantes informaron dolor intermitente continuo después de la cirugía que afectó significativamente varios aspectos de sus vidas. Esto impulsó a los participantes a adaptar su estilo de vida y explorar métodos alternativos de alivio del dolor, ya que algunos dudaban en confiar en los analgésicos.LIMITACIONES:El pequeño tamaño de la muestra de un solo centro en el que todos los pacientes se sometieron a una exanteración pélvica curativa para el cáncer rectal recurrente inferior y ninguno se sometió al procedimiento para paliar limita la generalización de los resultados de este estudio.CONCLUSIONES:Si bien el dolor crónico posterior a la exanteración pélvica para el cáncer rectal recurrente local interfiere con la calidad de vida post operatoria del paciente, el uso de analgésicos se vio influenciado por la habituación al dolor y el miedo a la dependencia de los analgésicos. Nuestros hallazgos enfatizan la necesidad de investigar aún más un enfoque multidisciplinario, que incluya métodos no farmacológicos, para optimizar los resultados del dolor después de la exanteración pélvica. (Traducción-Dr. Mauricio Santamaria ).

Pain, pain management and related outcomes following pelvic exenteration surgery: a systematic review

AIM

Pelvic exenteration surgery can improve survival in people with advanced colorectal cancer. This systematic review aimed to review pain intensity and other outcomes, for example the management of pain, the relationship between pain and the extent of surgery and the impact of pain on short-term outcomes.

METHOD

Electronic databases were searched from inception to 1 May 2021. We included interventional studies of adults with any indication for pelvic exenteration surgery that also reported pain outcomes. Risk of bias was assessed using ROBINS-1.

RESULTS

The search found 21 studies that reported pain following pelvic exenteration [n = 1317 patients, mean age 58.4 years (SD 4.8)]. Ten studies were judged to be at moderate risk of bias. Before pelvic exenteration, pain was reported by 19%-100% of patients. Five studies used validated measures of pain intensity. No study measured pain at all three time points in the surgical journey. The presence of pain before surgery predicted postoperative adverse pain outcomes, and pain is more likely to be experienced in those who require wider resections, including bone resection.

CONCLUSION

Considering that pain following pelvic exenteration is commonly described by patients, the literature suggests that this symptom is not being measured and therefore addressed.

Implementation of a peri-operative pain-management algorithm reduces the use of opioid analgesia following pelvic exenteration surgery

AIM

This study aimed to investigate the implementation and pain-related outcomes of a peri-operative pain-management regimen for patients undergoing pelvic exenteration surgery at a university teaching hospital.

METHOD

This is a single-site prospective observational cohort study involving 100 patients who underwent pelvic exenteration surgery between January 2017 and December 2018. A pain-management algorithm regarding the use of opioid-sparing multimodal analgesia was developed between the departments of anaesthesia, pain management and intensive care. The primary outcomes were: compliance with a pain-treatment algorithm compared with a similar retrospective surgical patient cohort in 2013-2014; and requirements for regular doses of opioid analgesia at discharge, measured in oral morphine equivalent daily dose (oMEDD).

RESULTS

Following the introduction of a pain-management algorithm, regional anaesthesia techniques (spinal anaesthesia, transversus abdominus plane block, preperitoneal catheters or epidural analgesia) were used in 83/98 (84.7%) of the 2017-2018 cohort compared with 13/73 (17.8%) of the 2013-2014 cohort (p < 0.001). There was a reduction in the median dose of opioid analgesics (oMEDD) at time of discharge, from 150 mg (interquartile range [IQR]: 75.0-235.0 mg) in the 2013-2014 cohort to 10 mg (IQR: 0.00-45.0 mg) in the 2017-2018 cohort (p < 0.001). There was no change in pain intensity (assessed using the Verbal Numerical Rating Score) or oMEDD in the first 7 days following surgery.

CONCLUSION

Since implementation of a novel peri-operative pain-treatment algorithm, the use of opioid-sparing regional techniques and preperitoneal catheters has increased. Additionally, the dose of opioids required at the time of discharge has reduced significantly.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

The role of surgery for loco-regional and advanced urological cancers

PURPOSE OF REVIEW

There is a general misconception that surgery is the antithesis of palliation. However, symptom mitigation, the basic tenet of palliative interventions, can be achieved by invasive procedures. Surgical care, thus, plays an important role in palliative oncology, alongside radiation and systemic therapy. There is global movement to improve palliation in oncology, and thus it is timely to evaluate the role of surgical interventions can play in this setting.

RECENT FINDINGS

Many of the surgical interventions done with palliative intent were first established as curative options. Most studies looked at interventions for local control of primary tumour including extirpative surgeries, while some studies studied pain relief for bone metastases. Results show that patients have an acceptable survival outcome and complication rate comparable to those done in the curative setting. However, not all studies report functional outcomes and symptom-relief consistently, highlighting an unmet need.

SUMMARY

More studies are needed to further define the role of surgery in palliative care. Randomized controlled trials studying surgical intervention in the palliative setting will be challenging because of lack of equipoise, inherent bias in patient and disease characteristics in those who undergo surgery. Nonetheless, studies should endeavour to study symptom-free survival and PROMs as meaningful endpoints of interventions performed in a palliative setting rather than solely focus on hard oncological endpoints of survival.