Sucralfate for posttonsillectomy analgesia

Efficacy of sucralfate ointment in the prevention of acute proctitis in cancer patients: A randomized controlled clinical trial

Background:

Acute radiation proctitis (ARP) is a usual adverse effect in patients undergoing pelvic radiotherapy. The symptoms include diarrhea, rectal blood or mucus discharge, fecal urgency and tenesmus with pain. Sucralfate, an aluminum-based salt of sucrose octasulfate, is a cytoprotective agent that forms a coating barrier at injured sites by adhering to mucoproteins. It has been used in topical management of a wide variety of local lesion. This study was designed to evaluate the preventive effect of rectal sucralfate on acute radiotherapy induced proctitis.

Methods:

Seven percent sucralfate ointment was prepared for topical use. Drug quantification, chemical stability and microbial limit tests were performed carefully. In this randomized double blind placebo controlled trial, fifty-seven patients with pelvic malignancies undergoing radiotherapy were allocated to receive either 1 g of sucralfate or 1 g of placebo, given as a twice daily ointment, one day before and during radiotherapy for six weeks. The eligible patients were evaluated based on RTOG acute toxicity criteria and the following ARP symptoms weekly: rectal hemorrhage, diarrhea, rectal pain, and fecal urgency. The influence of symptoms on lifestyle was also recorded weekly.

Results:

Acute proctitis was significantly less prevalent in patients in the sucralfate group. The incidence of rectal bleeding (P=0.003), diarrhea (P=0.002), rectal pain (P=<0.001) and fecal urgency (P=0.002) was significantly less common in the sucralfate group. No statistical significant difference was observed for radiotherapy induced cystitis in the placebo and sucralfate groups (P=0.27).

Conclusion:

This study suggests that sucralfate7% ointment reduces the incidence of symptoms associated with acute radiation proctitis.

The effect of applying amniotic membrane on post-tonsillectomy pain and bleeding

PURPOSE

Pain and hemorrhage are common morbidities after tonsillectomy. Although many studies have focused on post-tonsillectomy pain, inadequate researches are available on wound healing. Hence, there is a definite need for a novel technique to facilitate the healing process and thereby improving the post-tonsillectomy recovery.

METHODS

This prospective and randomized study was conducted on 60 adult patients who underwent tonsillectomy. They were divided into two groups of control and amniotic membrane (AM). Human amniotic membrane was applied over the tonsillar bed as a biologic dressing. Post-tonsillectomy pain and bleeding were evaluated. Also, the healing rate was assessed on days 5, 10 and 15 post-operatively.

RESULTS

The pain score in the AM group was lower than that in the control group during the first week after surgery (P < 0.0001). Moreover, the AM group returned faster to their normal diet in comparison with the control group (P < 0.0001). With respect to the healing rate, there were no significant differences between the groups on day 5 (P > 0.05), whereas a significant difference was seen on days 10 and 15 post-surgery (P < 0.0001). There was no significant difference between the two groups in terms of post-operative bleeding (P ≅ 1).

CONCLUSION

We observed that the use of AM graft as a biologic dressing might be beneficial in reducing post-operative pain and promoting the wound healing process. The results represent a further step toward developing a new technique for coverage of tonsillar fossa with sheeting or wearing grafts.

Wound healing after tonsillectomy - a review of the literature

OBJECTIVE

To summarise the available literature related to wound healing post tonsillectomy, including the stages of healing, experimental models for assessing healing (in animals and humans) and the various factors that affect wound healing.

METHODS

A search of the English literature was conducted using the Ovid Medline database, with the search terms 'tonsillectomy' or 'tonsil' and 'wound healing'. Thirty-one articles that objectively assessed tonsillectomy wound healing were included for analysis.

RESULTS

The majority of assessments in humans investigating tonsillectomy wound healing involve serial direct clinical examinations of the oral cavity. Many patient and surgical factors have been shown to affect wound healing after tonsillectomy. There is some research to suggest that the administration of adjunctive treatment in the post-operative period may be beneficial to tonsillectomy wound healing.

CONCLUSION

Wound healing post tonsillectomy has been poorly researched. Having a better understanding of the process of wound healing would allow surgeons to potentially prevent, anticipate and manage complications from the surgery that arise as part of the healing process.

Role of honey after tonsillectomy: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Honey reduced post-tonsillectomy pain, but its effects on awakening at night, inflammation and healing of the tonsillar fossa were controversial.

OBJECTIVES

This systematic review and meta-analysis of randomised controlled trials (RCTs) evaluated the effect of oral honey on pain, consumption of painkillers, awakening at night, healing of tonsillar fossa and adverse effects in children after tonsillectomy.

METHODS

A search of MEDLINE, EMBASE, Scopus, CINAHL and Cochrane Collaboration Library databases was performed without any restriction of publication year. The end date of search was 30 June 2016. The search was supplemented by search from Google, hand search of cross-references of selected articles and reviews, and contacting the authors of different studies. The inclusion criteria were RCTs comparing the effect of honey with control on different outcomes, in children after tonsillectomy.

RESULTS

Our search generated 64 studies, and eight RCTs met our inclusion criteria. The methodological quality of RCTs was poor. Compared to control, honey significantly decreased postoperative pain from day 1 to day 7 (P = 0.05 to <0.0001); consumption of painkillers from days 1 to 5 (P = 0.03 to 0.003) and on day 10 (P = 0.002); and number of awakening at night due to pain on days 2 and 4 after tonsillectomy (P = 0.0001, 0.004). The healing of tonsillar fossa was significantly greater with honey compared to control on days 3-4 (P = 0.02) and days ≥9 (P = 0.01) after tonsillectomy. The adverse effects were not significantly different between honey and control groups. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) of the evidence for different outcomes varied from 'low' to 'very low'.

CONCLUSIONS

Honey improved pain, requirement of painkillers and awakening at night due to pain in children after tonsillectomy. There was little improvement in healing of tonsillar fossa. The GRADE of the evidence varied from 'low' to 'very low'. A good-quality, placebo-controlled RCT of different doses and durations of administration of honey is required to evaluate its clear efficacy and safety in children after tonsillectomy.

Celecoxib Versus Placebo in Tonsillectomy

Objectives:

Celecoxib is a cyclooxygenase-2-specific inhibitor indicated to treat acute pain and pain secondary to osteoarthritis and rheumatoid arthritis. Surgical models of acute pain have demonstrated superior pain relief to placebo. The objective of this study was to test the safety and efficacy of celecoxib for pain relief after tonsillectomy compared to placebo.

Methods:

Adult subjects were randomized to 200 mg celecoxib versus placebo with a loading dose the night before surgery then twice daily for 10 days. Subjects were instructed to supplement the study drug with hydrocodone/acetaminophen liquid or acetaminophen for pain as needed. Subjects completed a daily diary regarding their pain, nausea, vomiting, diet, and activity.

Results:

Seventeen subjects enrolled. Intraoperative blood loss was similar between groups, and no subject had postoperative bleeding. Three patients returned to the emergency department for treatment, and 2 patients could not complete the diaries, all in the placebo group. Subjects in the placebo group required statistically significant ( P < .05) higher doses of narcotic and acetaminophen to control pain. Pain and diet rating scores were slightly better in the celecoxib group compared to placebo.

Conclusions:

In this small cohort, celecoxib reduced postoperative narcotic and acetaminophen requirements compared to placebo without complications.

Efficacy of Sucralfate Mouth Wash in Prevention of 5-fluorouracil Induced Oral Mucositis: A Prospective, Randomized, Double-Blind, Controlled Trial

Sucralfate has been used for the prevention and treatment of radiotherapy- and chemotherapy-induced stomatitis and mucositis in a number of studies, but the results are contradictory. To answer such discrepancies, the present study was designed to evaluate the efficacy of sucralfate mouthwash in prevention of 5-fluorouracil (5-FU)-induced oral mucositis in patients with gastrointestinal malignancies. Patients with gastrointestinal cancers receiving 5-FU-based chemotherapy regimens were included in this randomized, blinded, controlled trial and were randomly allocated to either sucralfate mouthwash (every 6 h) or placebo. The patients were visited at fifth and tenth day of trial; the presence and severity of oral mucositis and the intensity of pain were assessed. The patients receiving sucralfate experienced lower frequency and severity of mucositis (76% vs. 38.5%, P = 0.005 and 84 vs. 38.5%, P < 0.001, respectively) and less intense pain (2.5 ± 2.2 vs. 5.08 ± 3.82, P = 0.004 and 1.33 ± 0.86 vs. 4.12 ± 3.5, P = 0.001, respectively) compared with the placebo group both at day 5 and day 10. Within the sucralfate group, a decrease in frequency and severity of mucositis was observed throughout the trial period, while in the placebo group no such effect was observed. Sucralfate mouthwash reduced the frequency and severity of 5-FU-induced oral mucositis in patients with gastrointestinal malignancies compared with placebo, indicating its efficacy in the prevention of chemotherapy-induced mucositis.

Efficacy of sucralfate for the treatment of post-tonsillectomy symptoms

Pain after tonsillectomy remains the main issue of postoperative morbidity and the search for an effective post-tonsillectomy analgesic is of increasing relevance. The aim of this study was to evaluate the effectiveness of topical sucralfate during an early post-tonsillectomy period. Fifty patients of both genders from 6 to 58 years submitted to tonsillectomy or adenotonsillectomy were randomly included into either a sucralfate treatment group (N = 25) or into a control group (N = 25). Patients of the sucralfate group received topical sucralfate four times a day for 7 days. No topical treatment was applied to patients of the control group. A systemic analgesic was standardized. Post-tonsillectomy symptoms, including throat pain, odynophagia and otalgia, were evaluated during the period of seven postoperative days. Secondary outcomes were analgesic use, well being in general, return to regular daily activities, secondary hemorrhage and side effects of sucralfate. This study revealed that during the period of the second to seventh postoperative days average throat pain scores of the sucralfate using patients were significantly lower than those of the control group patients (p < 0.05); the same could be applied to odynophagia scores during the period of all seven postoperative days (p < 0.01) and otalgia scores from the 4th postoperative day (p < 0.05). The sucralfate group patients also had a significantly smaller need for analgesics, better scores of well being in general and early return to regular daily activities with no side effects of the treatment. Topical sucralfate could be recommended for the everyday clinical practice as a safe, adjuvant medicine of treatment during the period of the first post-tonsillectomy week.

Topical sucralfate in post-adenotonsillectomy analgesia in children: a double-blind randomized clinical trial

OBJECTIVES

Tonsillectomy, with or without adenoidectomy, is one of the most common surgical procedures in pediatric otolaryngology. Despite its relative simplicity, pain is the main cause of morbidity in the postoperative period. We determined the effect of topical sucralfate on reduction of oropharyngeal pain in children submitted to adenotonsillectomy. Secondary outcomes were otalgia, analgesic use, type of diet, secondary bleeding, vomiting, fever, and weight loss.

STUDY DESIGN

Double-blind, randomized clinical trial.

SETTING

Tertiary hospital.

SUBJECTS AND METHODS

Eighty-two children of both sexes between four and 12 years old submitted to adenotonsillectomy were evaluated. They were allocated to receive topical sucralfate or placebo in intraoperative and postoperative periods four times a day for five days. Pain was measured through faces pain scale.

RESULTS

Reduction in oropharyngeal pain was significant with use of sucralfate during five days of evaluation (mean, 95% confidence interval, and P value); day 1: 2.05, 1.53-2.58, P = 0.000; day 2: 2.1, 1.51-2.70, P = 0.001; day 3: 1.44, 0.88-1.99, P = 0.003; day 4: 1.13, 0.58-1.55, P = 0.027; day 5: 0.67, 0.26-1.04, P = 0.021). There was no difference in secondary outcomes.

CONCLUSION

We found beneficial effect of use of sucralfate in reduction of oropharyngeal pain in the postoperative period of adenotonsillectomy. However, topical sucralfate does not have a potent effect to the point of being utilized as a single analgesic treatment. Because it is simple, safe, tolerated, and low-cost, it is an important tool as adjuvant treatment of post-tonsillectomy pain.

Apnea in a child after oral codeine: a genetic variant - an ultra-rapid metabolizer

We present a case of a 29 months old previously healthy child who experienced apnea resulting in brain injury following a dose of acetaminophen and codeine 2 days after an uneventful anesthetic for tonsillectomy. A genetic polymorphism leading to ultra-rapid metabolism of codeine into morphine resulted in narcosis and apnea. This paper discusses the use of codeine for pain relief, obstructive sleep apnea, the alteration of the CYP2D6 gene and the resulting effect on drug metabolism.

Evaluation of early postoperative morbidity in pediatric tonsillectomy with the use of sucralfate

OBJECTIVE

The objective of this study is to evaluate the efficacy of sucralfate in alleviating posttonsilectomy morbidity in a pediatric group of patients.

METHODS

A prospective, double-blind, randomized, and placebo-controlled study comparing the irrigation of a solution containing either 1g of sucralfate (study group) or 1g of lactulose (control group) was performed on 69 children aged 3-12 years, who underwent tonsillectomy at the University Hospital of Brasilia Medical School. The children were randomly assigned and each one used a solution containing sucralfate or lactulose to swish and swallow four times daily during 7 days. Eleven patients were excluded. The anesthetic was standardized and no premedication was used. Pain magnitude using an "Oucher" scale, nausea, vomiting, bleeding, earache, analgesic drug intake, changes in the interincisor teeth distance, and changes in the weight and temperature were assessed by the surgeon 6, 24h, and 7 days after the surgery.

RESULTS

Patients in the study group had significantly lower pain scores in the initial 6 postoperative hours (p<0.05). The difference between the two groups was not statistically significant for the other periods following the procedure or on the evaluation of the other indices.

CONCLUSIONS

The use of the sucralfate in pediatric patients undergoing tonsillectomy was not effective in reducing the postoperative morbidity according to the parameters used in this study. The surgical technique with careful mucosal dissection associated with postoperative caries could be more important in the reduction of posttonsilectomy morbidity.

Can postoperative pains following tonsillectomy be relieved by honey? A prospective, randomized, placebo controlled preliminary study

OBJECTIVE

To compare the effectiveness of acetaminophen versus acetaminophen-plus-honey following pediatric tonsillectomy and adenoidectomy.

DESIGN

Prospective, randomized, and placebo controlled clinical trial.

SETTING

Tertiary care facility in Ankara, Turkey.

PATIENTS

Sixty consecutive tonsillectomy patients randomized to two groups.

INTERVENTIONS

The acetaminophen group was treated with antibiotics (amoxicillin-clavulonic acid), acetaminophen and placebo, acetaminophen-plus-honey group was treated with antibiotics (amoxicillin-clavulonic acid), acetaminophen, and honey. Visual analogue scale (VAS) was applied for subjective assessment of postoperative pains, while the number of painkillers taken daily and awakening at night due to pain were used for objective assessment. The amount of epithelization was used for assessment of tonsillary fossa recovery.

OUTCOME MEASURES

The difference between acetaminophen and acetaminophen-plus-honey groups was statistically significant both in terms of VAS and number of painkillers taken within the first 2 postoperative days (p<0.001). Although there was no statistically significant difference between groups regarding the VAS scores on the 3rd postoperative day and after, the number of painkillers taken differed significantly until the 8th postoperative day (p<0.001 for first 7 postoperative days; p=0.003 for 8th day). No significant difference was found between groups regarding the number of awakening at night (p=0.36). Tonsillary fossa epithelization was more rapid in the acetaminophen-plus-honey group (p<0.001).

CONCLUSION

Oral administration of honey following pediatric tonsillectomy may relieve postoperative pain and may decrease the need for analgesics. Prospective, randomized, and double-blind studies should further be conducted in order to confirm the data obtained in this study and develop a standard protocol to achieve maximum clinical efficiency.

Improved postoperative pain control in pediatric adenotonsillectomy with dextromethorphan

DESIGN

A prospective, randomized, double-blinded, placebo-controlled protocol.

SETTING

An academic, tertiary care referral center.

PATIENTS

Forty randomly selected children, ages 3 to 13 years, scheduled for adenotonsillectomy without other simultaneous procedures.

INTERVENTION

A single, oral dose of dextromethorphan pediatric cough syrup (1 mg/kg) or placebo given 30 minutes before surgery.

MAIN OUTCOME MEASURE

Total dose requirement of intravenous morphine within a 6-hour postoperative observation period.

RESULTS

During routine postoperative observation, significantly fewer patients in the dextromethorphan group required no intravenous morphine compared with the placebo group (P =.03). Of those children requiring morphine, the mean dose requirement was significantly lower in the dextromethorphan group (P =.02). There was no known drug-related morbidity.

CONCLUSION

Dextromethorphan syrup is a safe, non-narcotic medication that significantly reduced the requirement of intravenous morphine after pediatric adenotonsillectomy. Its routine use in this manner is recommended.

Evaluating the effects of oral prednisolone on recovery after tonsillectomy: a prospective, double-blind, randomized trial

OBJECTIVES

To investigate the role of a 7-day course of oral prednisolone on recovery from tonsillectomy.

STUDY DESIGN

Double-blind, randomized, placebo-controlled trial of 50 consecutive patients, aged 5 years and older, who had no previous or known contraindications to steroid therapy.

METHODS

The patients were randomized at the time of surgery to either a 7-day course of daily placebo or prednisolone (dosage: 10 mg per day in patients aged 5-11 y, 0.5 mg/kg in those aged 12 and older). Age, sex, weight, diagnosis, tonsil size (in cm2), additional adenoidectomy, performing surgeon, method of dissection, length of procedure, total blood loss, intraoperative fluid requirement, and length of hospitalization were documented for each patient. During the first postoperative day, morning pain score, paracetamol use, oral fluid intake, temperature, presence of nausea and vomiting, level of activity (low, moderate, or normal), and type of diet (liquid, soft, or normal) were recorded.

RESULTS

The steroid group consisted of a greater number of diathermy dissection cases and had significantly less intraoperative blood loss (P value = .022 and .017, respectively). On postoperative days 4 to 7, the steroid group experienced less nausea and vomiting (P value = .01, .04, .04, and .04, respectively). Paracetamol use was less in the steroid group on days 2, 7, and 8 (P value = .03, .02, and .02, respectively). There was no difference between the two groups for the other data measured.

CONCLUSION

A 7-day course of corticosteroids may play a limited role in patients' recovery from tonsillectomy.