Pain, psychosocial tests, pain sensitization and laparoscopic pelvic surgery

Updates in Enhanced Recovery Pathways for Gynecologic Surgery

Gynecologic surgery encompasses over a quarter of inpatient surgical procedures for US women, and current projections estimate an increase of the US female population by nearly 50% in 2050. Over the last decade, US hospitals have embraced enhanced recovery pathways in many specialties. They have increasingly been used in multiple institutions worldwide, becoming the standard of care for patient optimization. According to the last updated enhanced recovery after surgery (ERAS) guideline published in 2019, there are several new considerations behind each practice in ERAS protocols. This article discusses the most updated evidence regarding ERAS programs for gynecologic surgery.

The impact of preoperative pelvic pain on outcomes after vaginal reconstructive surgery

BACKGROUND

Pelvic pain is a debilitating condition that is common among women with pelvic floor disorders. Limited information is known about the impact of preoperative pelvic pain on outcomes after vaginal reconstructive surgery.

OBJECTIVE

This study aimed to compare the outcomes after vaginal reconstructive surgery between women with and without preoperative pelvic pain.

STUDY DESIGN

Baseline and postoperative data were analyzed from the "Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial." The multicenter trial involved women with anterior prolapse without symptoms of stress incontinence randomized to receive either a midurethral sling or sham incisions during a vaginal reconstructive surgery. Participants completed the visual analog scale adapted for suprapubic pain and Pelvic Floor Distress Inventory at baseline, 3 months, and 12 months. Preoperative pelvic pain was defined as a response of "5" or greater on pain on the visual analog scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question, "Do you usually experience pain in the lower abdomen or genital area?" Outcomes and complication rates were compared between women with and without pelvic pain.

RESULTS

The "Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial" participants included 112 women with pelvic pain (58 had a midurethral sling and 54 had sham incisions) and 212 women without pelvic pain (105 had a midurethral sling and 107 had sham incisions). Women who had a midurethral sling and pelvic pain were younger than women without pelvic pain (60.3±12.1 vs 65.1±8.6; P=.004). Women who had sham incisions and pelvic pain were more likely of Hispanic ethnicity than women without pelvic pain (27.8% vs 9.4%; P=.002). Patient improvement based on the Patient Global Impression of Improvement scale did not differ between arms. Women with pelvic pain had greater improvement on the visual analog scale pain scores after a surgical procedure at 3 months (-3.1±2.9 vs -0.4±1.6; P<.001) and at 12 months (-3.4±3.0 vs -0.6±1.6; P<.001) than women without pain, although their pain scores remained higher than those without preoperative pelvic pain at all time points (P<.001 for all). Similar improvements were found on the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. The differences observed were not affected by whether women were in the midurethral sling or sham arm of the trial. Postoperative urinary tract infection and incomplete bladder emptying did not differ between the groups.

CONCLUSION

Women with preoperative pelvic pain experienced significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery and had similar subjective improvement postoperatively compared with women without preoperative pelvic pain. Reassuringly, the performance of a midurethral sling did not have an impact on the results.

A Multimodal Protocol to Diminish Pain Following Common Orthopedic Sports Procedures: Can We Eliminate Postoperative Opioids?

PURPOSE

To determine whether postsurgical pain, measured by the visual analog scale (VAS), following common orthopaedic sports procedures could be managed effectively with a nonopioid multimodal analgesic protocol.

METHODS

This prospective study evaluated a custom multimodal nonopioid pain protocol in patients undergoing common orthopaedic sports procedures by a single fellowship-trained orthopaedic sports surgeon from May 2018 to December 2018. Procedures included anterior cruciate ligament reconstruction, rotator cuff repair, arthroscopic partial meniscectomy, and labrum repair. The nonopioid pain protocol consisted of preoperative analgesics, intraoperative local infiltration analgesia, and a postoperative pain regimen. Patient pain was immediately reported after surgery and 1 week postoperatively using the VAS, whereas rescue opioids (oxycodone 5 mg) used were recorded using a prescription opioid journal. Statistical analysis of patient VAS scores, demographic correlations, and comparison between opioid rescue users versus nonusers was performed.

RESULTS

A total of 141 patients were included. One week following surgery, patients reported a mean VAS level of 3.2 ± 2.3 and required on average 2.6 ± 3.6 breakthrough oxycodone pills (8.6 ± 12.0 morphine equivalents). Forty-five percent of patients did not require any breakthrough prescription opioids and reported satisfaction with pain management. Patients who required opioids were more likely to have a history of anxiety/depression (44.2% vs 23.8%, P = .012) and reported greater pain scores as compared with nonusers (3.94 ± 2.5 vs 2.41 ± 1.75, P = .016). The most common side effect of the pain protocol was feeling drowsy (23.5%). All patients were satisfied with their pain management postoperatively.

CONCLUSIONS

A multimodal, nonopioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures. Patients were found to have low levels of pain, require minimal rescue opioids, and had no severe side effects related to the protocol. These results suggest a nonopioid alternative to pain management following common orthopedic sports procedures.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Hepatoprotective effect of the unsaponifiable matter from olive, linseed and sesame oils against carbon tetrachloride-induced liver injury in rats

In the present study, the hepatoprotective activity of the unsaponifiable matter (UNSAP) of olive oil, linseed, and sesame oils against CCl4-induced liver toxicity in rats was investigated. In a preliminary antioxidant study, UNSAP showed pronounced DPPH radical scavenging activity (IC50 6.2-10.8 mg/mL). The constituents of UNSAP were determined by GC-MS. The subcutaneous administration of CCl4, caused liver injury. The hepatoprotective effect of UNSAP was comparable to that of α-tocopherol, a standard antioxidant agent. The co-administration of the investigated UNSAP normalized the activities of serum marker enzymes, alanine aminotransferase (ALT), and aspartate aminotransferase (AST). Furthermore, the serum alkaline phosphatase (ALP) activity and hepatic malondialdehyde (MDA) level were found to be alleviated by pre-treatment with the UNSAP. A histopathological evaluation showed marked improvement in the liver of UNSAP- and α-Tocopherol-treated animals. The hepatoprotective effect could be attributed to the antioxidant characteristics of UNSAP.