The efficacy of transdermal fentanyl for pain relief after endoscopic submucosal dissection: a prospective, randomised controlled trial

Associations between Clinicopathological Characteristics and Intraoperative Opioid Requirements during Endoscopic Submucosal Dissection with Monitored Anesthesia Care: A Retrospective Study

Background and study aims: Endoscopic submucosal dissection is used to treat early gastric neoplasms. Compared with other endoscopic procedures, it requires higher doses of opioids, leading to adverse events during monitored anesthesia care. We investigated the correlations between clinicopathological characteristics and intraprocedural opioid requirements in patients who underwent endoscopic submucosal dissection under monitored anesthesia care. Patients and methods: The medical records of patients who underwent endoscopic submucosal dissection under monitored anesthesia care were retrospectively reviewed. The dependent variable was the total dose of fentanyl administered during the dissection, while independent variables were patient demographics, the American Society of Anesthesiologists physical status classification, preoperative vital sign data, and the pathological characteristics of the neoplasm. Correlations between variables were examined using multiple regression analysis. Results: The study included 743 patients. The median total fentanyl dose was 100 mcg. Younger age (coefficient -1.37; 95% confidence interval [CI] -1.78 to -0.95), male sex (16.12; 95% CI 6.99-25.24), baseline diastolic blood pressure (0.44; 95% CI 0.04-0.85), neoplasm length (1.63; 95% CI 0.90-2.36), and fibrosis (28.59; 95% CI 17.77-39.42) were positively correlated with the total fentanyl dose. Total fentanyl dose was higher in the differentiated (16.37; 95% CI 6.40-26.35) and undifferentiated cancers group (32.53; 95% CI 16.95-48.11) than in the dysplasia group; no significant differences were observed among the others. The mid-anterior wall (22.69; 95% CI 1.25-44.13), mid-posterior wall (29.65; 95% CI 14.39-44.91), mid-greater curvature (28.77; 95% CI 8.56-48.98), and upper groups (30.06; 95% CI 5.01-55.12) had higher total fentanyl doses than the lower group, whereas doses did not significantly differ for the mid-lesser curvature group. Conclusions: We identified variables that influenced opioid requirements during monitored anesthesia care for endoscopic submucosal dissection. These may help predict the needed opioid doses and identify factors affecting intraprocedural opioid requirements.

Effects of transcutaneous electrical acupoint stimulation (TEAS) on postoperative pain in patients undergoing gastric and esophageal ESD surgery: a study protocol for a prospective randomized controlled trial

BACKGROUND

Post-operative pain of endoscopic submucosal dissection (ESD) is always be overlooked and undertreated by endoscopists. However, the incidence of moderate to severe pain after ESD is as high as 44.9% to 62.8%, which can greatly affect the patient's recovery, reduce their satisfaction, and extend their hospital stay. Transcutaneous electrical acupoint stimulation (TEAS) have been shown to reduce postoperative pain and enhance gastrointestinal (GI) function recovery in patients undergoing abdomen surgery. However, there is no evidence regarding on the effect of TEAS on post-operative pain and complications in patients undergoing ESD. Therefore, we aim to investigate whether perioperative TEAS treatment is superior to the sham acupuncture in terms of post-ESD pain and GI function recovery.

METHODS

This study is a prospective, randomized controlled trail, which is single-blinded and in single center. A total of 120 patients undergoing elective gastric and esophageal ESD surgery in Beijing Friendship Hospital, Capital Medical University, will be involved in this study. These individuals will be stratified according to the type of ESD surgery (i.e. gastric or esophageal procedure) and be randomly divided into two groups. L14, PC6, ST36 and ST37 will be stimulated at the TEAS treatment group, and the control group will receive simulation at four sham acupoints. The primary outcome is post-EDS VAS score at the time of entering PACU, 10 min, 20 min, 30 min, 1 h, 2 h, 4 h, 6 h, 18 h, 24 h, 48 h after the surgery. The secondary outcomes include the anesthesia-associated parameters, sedation score, nausea and vomiting score, shivering score, recovery of gastrointestinal function, satisfaction of patients to anesthesia, incidence of postoperative complications, QLQ-C30 life quality scale, and the economic indicators.

DISCUSSION

The results of this study will confirm that continuous preventive application of TEAS can alleviate the postoperative pain among patients with gastric and esophageal ESD surgery and accelerate the recovery of post-ESD gastrointestinal function.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ID: ChiCTR2100052837, registered on November 6, 2021. http://www.chictr.org.cn/showproj.aspx?proj=135892 .

Intraoperative Dexmedetomidine Decreases Postoperative Pain after Gastric Endoscopic Submucosal Dissection: A Prospective Randomized Controlled Trial

BACKGROUND

Postoperative pain is one of the most common complications after gastric endoscopic submucosal dissection (ESD); however, there have been only a few studies assessing the efficacy of interventions on postoperative pain after gastric ESD. This prospective randomized controlled trial was designed to assess the effect of intraoperative dexmedetomidine (DEX) on postoperative pain after gastric ESD.

MATERIALS AND METHODS

A total of 60 patients undergoing elective gastric ESD under general anesthesia were randomly divided into the DEX group receiving DEX with a loading dose of 1 μg/kg, followed by a maintenance dose of 0.6 μg/kg/h until 30 min before the end of the endoscopic procedure, and the control group receiving normal saline. The primary outcome was the visual analog scale (VAS) score of postoperative pain. Secondary outcomes were the dosage of morphine for postoperative pain control, hemodynamic changes during the observable period, the occurrence of adverse events, lengths of postanesthesia care unit (PACU) and hospital stays, and patient satisfaction.

RESULTS

The incidence of postoperative moderate to severe pain was 27% and 53% in the DEX and control groups, respectively, with a significant difference. Compared to the control group, VAS pain scores at 1 h, 2 h, and 4 h postoperatively, the dosage of morphine in the PACU, and the total dosage of morphine within 24 h postoperatively were significantly decreased in the DEX group. Both incidences of hypotension and use of ephedrine in the DEX group were significantly decreased during surgery, but they were significantly increased in the postoperative period. Postoperative nausea and vomiting scores were decreased in the DEX group; however, the length of PACU stay, patient satisfaction, and duration of hospital stay were not significantly different between groups.

CONCLUSION

Intraoperative DEX can significantly decrease postoperative pain level, with a slightly reduced dosage of morphine and a decreased severity of postoperative nausea and vomiting after gastric ESD.

Efficacy of dexmedetomidine on postoperative pain in patients undergoing gastric and esophageal endoscopic submucosal dissection: a study protocol for a randomized controlled prospective trial

BACKGROUND

Endoscopic submucosal dissection (ESD) is widely used as an effective treatment of early gastric and esophageal tumors, as it is minimally invasive, safe, and convenient. Epigastric pain is a common complication of ESD. In the traditional cognition, the postoperative pain of ESD is not serious and does not attach too much attention. However, previous studies found that the incidence of moderate to severe pain after ESD can be as high as 44.9~62.8%. At present, there is no unified understanding of how to carry out good postoperative analgesia in patients undergoing ESD of stomach and esophagus. The purpose of present study is to investigate the efficacy of intraoperative dexmedetomidine (DEX) using on postoperative pain though observing the postoperative visual analog scale (VAS) score within 48 h after ESD surgery, so as to explore an effective analgesia and anesthetic method in patients undergoing gastric and esophagus ESD.

METHODS/DESIGN

This study is a prospective, single-center, two-arm, randomized control trail. In total, 120 patients undergoing endoscopic submucosal dissection were stratified by type of surgery (i.e., gastric or esophagus ESD) and randomized into two treatment groups, DEX group (group D, n = 60) and control group (group C, n = 60). Patients in the experimental group (DEX group) will be administrated a loading dose of DEX at 1 μg/kg for 15 min and a continuous infusion at 0.6 μg/kg/h until 30 min before the end of operation. In control group, the same volume of normal saline was infused. The primary outcome is VAS at 2 h after ESD surgery. The secondary outcome will be VAS at 1 h, 4 h, 6 h,18 h, 24 h, and 48 h, the status of perioperative hemodynamics, the use of remedial analgesics, sedation score, shivering, postoperative nausea and vomiting (PONV), and satisfaction scores of patient and complication of ESD (such as bleeding, perforation, aspiration pneumonia).

DISCUSSION

The results of this study will demonstrate that intraoperative application of DEX is beneficial for postoperative pain treatment in patients undergoing ESD. This study will not only confirm that postoperative pain treatment is necessary for patients undergoing ESD but also provides an effective anesthesia method for postoperative analgesia.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ID: ChiCTR2100043837 , registered on March 4, 2021, http://www.chictr.org.cn .

Efficacy of submucosal bupivacaine injection for pain relief after endoscopic submucosal dissection: A multicenter, prospective, randomized controlled, and double-blind trial

BACKGROUND AND AIM

Although abdominal pain is a common adverse event related to endoscopic submucosal dissection (ESD), it can be sometimes underestimated by endoscopists. There are some endoscopic interventions available for the prevention of post-ESD pain, but their efficacy has not been established. We investigated whether a submucosal injection of bupivacaine (BP) can reduce procedure-related abdominal pain compared with the standard method.

METHODS

We performed a multicenter, double-blinded, randomized controlled trial of 86 adult patients referred for ESD as treatment for gastric neoplasms. Patients were randomly assigned to either the BP submucosal or conventional solution group. Questionnaires were collected when the study began (baseline) and immediately after ESD, as well as at 6, 12, and 24 hours post-operatively. The primary outcome was indicated by the visual analog scale (VAS) evaluated at 6 hours after procedure.

RESULTS

There were no significant differences in primary outcomes between groups and among all time points (immediately, 12, and 24 hours after ESD). The VAS and short-form McGill pain (SF-MP) scores were higher immediately after ESD than at 6, 12, or 24 hours post-operatively. The incidence of abdominal pain immediately after ESD was 94.0% (78/83) for all patients of both groups, and there was no significant difference between the 2 groups in the rate of abdominal pain immediately after ESD (BP group 37/40 [92.5%] versus non-BP group 41/43 [95.3%], P = .934). In univariable and multivariable analyses, BP did not have protective effect on post-ESD abdominal pain.

CONCLUSIONS

Submucosal BP injection does not promote pain relief or mitigate the effects of post-ESD abdominal pain.

A Comparative Randomized Trial on the Optimal Timing of Dexamethasone for Pain Relief after Endoscopic Submucosal Dissection for Early Gastric Neoplasm

Background/Aims

The aim of this study was to compare the clinical effects of preoperative and postoperative dexamethasone on pain after endoscopic submucosal dissection (ESD) for early gastric neoplasm.

Methods

Forty patients with early gastric neoplasm who were scheduled for ESD were randomized into two groups according to the timing of steroid administration: preoperative (“pre”, n=20) and postoperative (“post”, n=20) steroid administration. The pre group received 0.15 mg/kg dexamethasone before ESD and placebo after, and the post group received pre-ESD placebo and post-ESD dexamethasone. The present pain intensity (PPI) index and the short-form McGill pain (SF-MP) questionnaire were evaluated.

Results

The primary outcome was PPI score at 6 hours after ESD. There was a greater reduction in 6-hour PPI in the pre group than in the post group (2.1±0.8 vs 3.0±1.1, respectively; p=0.006). The immediate PPI was also significantly lower in the pre group than in the post group (1.6±0.6 vs 2.9±0.6, respectively; p<0.001), and the total SF-MP scores were significantly lower in the pre group than in the post group both immediately and at 6 hours after the operation.

Conclusions

Preoperative administration of dexamethasone may produce a superior analgesic effect in patients who undergo ESD compared with the postoperative administration of dexamethasone.

Accessory Devices Frequently Used for Endoscopic Submucosal Dissection

Endoscopic submucosal dissection (ESD) is increasingly being considered an essential component of treatment for early gastrointestinal cancers and subepithelial tumors. The ESD technique owes its popularity to the development of sophisticated instruments used for ESD. With an increase in the number of ESD procedures performed, there is rapid development in the number and types of endoscopic accessory devices used for such procedures. Despite the large numbers of new devices developed and marketed, the use of ESD instruments and accessory devices is largely determined by individual preferences and experiences. Accessory devices frequently used during ESD are important tools for ESD techniques. Each instrument possesses characteristic advantages and disadvantages associated with its use, and no one instrument is superior in all respects to others. In this article, we review the characteristics of endoscopic electrical knives, cap and hood, and hemostatic devices commonly used in ESD.

Predictive Factors for Pain After Endoscopic Resection of Gastric Tumors

BACKGROUND

Abdominal pain is a common complaint following endoscopic resection (ER).

AIMS

To investigate the predictive factors for abdominal pain after ER.

METHODS

Patients who were scheduled to undergo endoscopic mucosal resection or endoscopic submucosal dissection for the treatment of gastric adenoma or cancer were prospectively enrolled. Pain scores were checked every 6 h after ER and whenever patients complained of pain by using a 0-10 pain scale. If the pain score exceeded 5, 25 mg of intravenous (IV) pethidine was administered.

RESULTS

Among 156 patients who underwent ER, 66 (42.3 %) received IV pethidine due to moderate/severe abdominal pain. Both the number of patients complaining of abdominal pain and the pain scores decreased with time following the procedure, with only a few patients complaining of mild abdominal pain 2 days after ER. Multivariate analysis showed that female sex [odds ratio (OR) 2.88; confidence interval (CI) 1.31-6.33], tumor location in the lower third of the stomach (OR 5.46; CI 2.31-12.92), and procedures time more than 60 min (OR 2.96; CI 1.26-6.98) were significant predictive factors for developing pain after ER.

CONCLUSIONS

Female sex, tumor location in the lower third of the stomach, and longer procedure time were significantly associated with pain after ER. Close monitoring and active management of pain is recommended for patients who have these risk factors. With these efforts, the majority of patients could experience pain relief within 2 days after the procedure.

Complications of endoscopic resection techniques for upper GI tract lesions

Adverse events can occur during and after the endoscopic resection of upper gastrointestinal lesions. Their incidence can be minimized through the adoption of preventive measures and their final outcomes can be optimized through prompt identification and adequate treatment. In this evidence-based review we describe the risk factors for adverse events, preventive measures to avoid them and their management when they occur. Algorithms of action are also provided. Oesophageal strictures can be prevented with corticosteroids (either locally injected or systemically administered) and treated with endoscopic dilatation. Bleeding can be minimized through the adoption of prophylactic coagulation and novel preventive measures are emerging and being evaluated. Bleeding management includes coagulation therapy, clips and haemostatic powders. Perforations can nowadays be successfully treated endoscopically in the majority of the cases and conservative treatment is associated with favourable outcomes although optimal management is unclear.

Efficacy of Intravenous Lidocaine During Endoscopic Submucosal Dissection for Gastric Neoplasm: A Randomized, Double-Blind, Controlled Study

Endoscopic submucosal dissection (ESD) is an advanced therapy for early gastric neoplasm and requires sedation with adequate analgesia. Lidocaine is a short-acting local anesthetic, and intravenous lidocaine has been shown to have analgesic efficacy in surgical settings. The aim of this study was to assess the effects of intravenous lidocaine on analgesic and sedative requirements for ESD and pain after ESD.Sixty-six patients scheduled for ESD randomly received either intravenous lidocaine as a bolus of 1.5 mg/kg before sedation, followed by continuous infusion at a rate of 2 mg/kg/h during sedation (lidocaine group; n = 33) or the same bolus and infusion volumes of normal saline (control group; n = 33). Sedation was achieved with propofol and fentanyl. The primary outcome was fentanyl requirement during ESD. We recorded hemodynamics and any events during ESD and evaluated post-ESD epigastric and throat pain.Fentanyl requirement during ESD reduced by 24% in the lidocaine group compared with the control group (105 ± 28 vs. 138 ± 37 μg, mean ± SD; P < 0.001). The lidocaine group reached sedation faster [40 (20-100) vs. 55 (30-120) s, median (range); P = 0.001], and incidence of patient movement during ESD decreased in the lidocaine group (3% vs. 26%, P = 0.026). Numerical rating scale for epigastric pain was significantly lower at 6 hours after ESD [2 (0-6) vs. 3 (0-8), median (range); P = 0.023] and incidence of throat pain was significantly lower in the lidocaine group (27% vs. 65%, P = 0.003). No adverse events associated with lidocaine were discovered.Administration of intravenous lidocaine reduced fentanyl requirement and decreased patient movement during ESD. Moreover, it alleviated epigastric and throat pain after ESD. Thus, we conclude that the use of intravenous adjuvant lidocaine is a new and safe sedative method during ESD.

Efficacy of fentanyl transdermal patch in the treatment of chronic soft tissue cancer pain

Background:

Cancer pain may be a major problem for health care providers worldwide. According to different studies reporting the pain severity, one-third of patients reported to have moderate to severe pain. Management of cancer pain is one of the most important goals of palliative care. Recently, different research results on the efficacy of opioid analgesics in chronic pain management have played a role to implement standards in pain control by government agencies worldwide.

Objectives:

This study aimed to investigate the efficacy of fentanyl transdermal patch in the treatment of chronic soft tissue cancer pain.

Patients and Methods:

In a prospective descriptive study, we evaluated 86 patients with soft tissue tumors with chronic pain referred to cancer institute of Imam Khomeini Hospital, Tehran, Iran, during 2006-2007. For all patients, transdermal fentanyl patch (25 μg/h) was administered. The appearance of patches was the same. Pain severity was measured by Visual Analogue Scale (VAS) initially and 24, 48 and 72 hours after the initiation of treatment.

Results:

Patients' characteristics and VAS score before the treatment were not significantly different (P > 0.05). According to our findings, the pain severity was significantly reduced after the treatment (P = 0.001). The incidence of adverse events in patients was significantly high (72%). The most common adverse events were sleepiness, nausea and vomiting in 30.2% and 18.6%, respectively.

Conclusions:

Transdermal fentanyl patch was an effective and safe method to reduce pain in patients with soft tissue tumors. Moreover, it could improve the quality of life in these patients, but adverse events occurred in approximately 72% of patients.

Gastric endoscopic submucosal dissection is safe for day patients

BACKGROUND/AIMS

Although the advantages of endoscopic submucosal dissection (ESD) are well established, there are important limitations that relate to its higher cost and higher rate of complications compared with endoscopic mucosal resection. This study assessed the therapeutic safety and efficacy of ESD in the treatment of small gastric dysplasia and early gastric cancer (EGC) located within the antrum in an outpatient setting, and it compared the results with those from patients admitted to hospital for ESD treatment.

METHODS

This study was a retrospective analysis of a prospectively maintained database. We reviewed consecutive patients with EGC or gastric dysplasia who underwent ESD between October 2007 and May 2008. The lesions were smaller than 2 cm and were located in the antrum. We analyzed 105 lesions in 105 patients. The patients were assigned to two groups according to each patient's preference.

RESULTS

The overall rates of complete resection were 98.1% in the inpatients group and 94.3% in the outpatients group. Immediate bleeding occurred in four inpatients, which included one patient in the outpatient group. Delayed bleeding occurred in one inpatient within 24 hours of the procedure. Macroperforations did not occur in either group. A microperforation was found in one outpatient.

CONCLUSIONS

The safety and efficacy of ESD used to treat small gastric tumors in the antrum in an outpatient setting appeared to be similar to the safety and efficacy of ESD used to treat patients who were admitted to the hospital.

Endoscopic submucosal tunnel dissection salvage technique for ulcerative early gastric cancer

Endoscopic submucosal dissection is an effective treatment modality for early gastric cancer (EGC), though the submucosal fibrosis found in ulcerative EGC is an obstacle for successful treatment. This report presents two cases of ulcerative EGC in two males, 73- and 80-year-old, with severe fibrosis. As endoscopic ultrasonography suggested that the EGCs had invaded the submucosal layer, the endoscopic submucosal tunnel dissection salvage technique was utilized for complete resection of the lesions. Although surgical gastrectomy was originally scheduled, the two patients had severe coronary heart disease, and surgeries were refused because of the risks associated with their heart conditions. The endoscopic submucosal tunnel dissection salvage technique procedures described in these cases were performed under conscious sedation, and were completed within 30 min. The complete en bloc resection of EGC using endoscopic submucosal tunnel dissection salvage technique was possible with a free resection margin, and no other complications were noted during the procedure. This is the first known report concerning the use of the endoscopic submucosal tunnel dissection salvage technique salvage technique for treatment of ulcerative EGC. We demonstrate that endoscopic submucosal tunnel dissection salvage technique it is a feasible method showing several advantages over endoscopic submucosal dissection for cases of EGC with fibrosis.