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Chronic post-surgical pain (CPSP) stands as a major health issue. The unchanged incidence over the last two decades underlines both the failure of predictive models developed until now and the lack of efficacy of common “preventive” strategies (pharmacotherapy and regional analgesic techniques) applied in current clinical practice. The recognition of CPSP as a disease and the release of a common definition of the condition is an important progress in the field. CPSP predictive scores exist but none has presently demonstrated an impact on patient care. New clinical directions based on the resolution of postoperative pain, a complex and highly dynamic process supported by individual pain trajectories, argue for predictive models and preventive strategies extended to the subacute pain period i.e. after hospital discharge.

International audience; The aim of this review was to update the recommendations for optimal pain management after open and laparoscopic or robotic prostatectomy. Optimal pain management is known to influence postoperative recovery, but patients undergoing open radical prostatectomy typically experience moderate dynamic pain in the immediate postoperative day. Robot-assisted and laparoscopic surgery may be associated with decreased pain levels as opposed to open surgery. We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) with PROcedure SPECific Postoperative Pain ManagemenT (PROSPECT) methodology. Randomised controlled trials (RCTs) published in the English language, from January 2015 until March 2020, assessing postoperative pain, using analgesic, anaesthetic and surgical interventions, were identified from MEDLINE, EMBASE and Cochrane Databases. Of the 1797 studies identified, 35 RCTs and 3 meta-analyses met our inclusion criteria. NSAIDs and COX-2 selective inhibitors proved to lower postoperative pain scores. Continuous intravenous lidocaine reduced postoperative pain scores during open surgery. Local wound infiltration showed positive results in open surgery. Bilateral transversus abdominis plane (TAP) block was performed at the end of surgery and lowered pain scores in robot-assisted procedures, but results were conflicting for open procedures. Basic analgesia for prostatic surgery should include paracetamol and NSAIDs or COX-2 selective inhibitors. TAP block should be recommended as the first-choice regional analgesic technique for laparoscopic/robotic radical prostatectomy. Intravenous lidocaine should be considered for open surgeries.

Objectif : Evaluer les trajectoires de douleur pour l’identification des patients a risque de douleur chronique apres hepatectomie pour don vivant de foie. Type d’etude : Etude retrospective des donneurs vivants (DoVi) de foie sur une duree de trois ans. Patients et methodes : Recueil des donnees chirurgicales et anesthesiques perioperatoires des DoVi de foie. Une trajectoire standard de douleur postoperatoire (DPO) a ete construite avec les donnees des patients ne presentant pas de douleur chronique post-chirurgicale (DCPC), a laquelle a ete comparee l’evolution postoperatoire des patients avec DCPC. Resultats : Soixante-cinq patients ont ete evalues (hommes/femmes : 35/30, âge median 34 ans). La chirurgie etait une bisegmentectomie hepatique pour 89 % des patients. Une analgesie peridurale a ete utilisee chez 66 %, les autres beneficiant d’une pompe de morphine. Le premier jour, 11 % et 37 % des patients ont rapporte une DPO severe (score > 6/10) au repos et au mouvement respectivement. Six patients (9 %) (trois hommes, trois femmes) presentaient des DCPC a trois mois et plus, sans correlation avec la technique d’analgesie. L’analyse des trajectoires de DPO a montre que les patients avec DCPC avaient presente des DPO plus intenses durant les premieres 24 heures ou une resolution anormale de leur DPO aigue. Conclusion : La DPO aigue chez les DoVi de foie est un facteur de risque de DCPC. L’identification des patients a risque par les trajectoires de DPO pourrait permettre une prise en charge plus precoce.

To assess pain trajectories in predicting risk of chronic postoperative pain (CPP) after liver resection for living donor transplantation.Retrospective analysis of patients undergoing liver resection for living donor transplantation during 3years.After recording perioperative data, patients presenting CPP at 3months were separated from patients without postsurgical pain problem in order to build a pain trajectory for liver donor patients without CPP. Postoperative course of liver donors with CPP was then compared to that standard pain trajectory.Sixty-five patients (30 females, 35 males) were included. Epidural analgesia was used in 66%; others received autocontrolled analgesia by morphine. Severe acute pain was expressed by 11% and 37% at rest and movement respectively on the first day. Chronic pain involved six patients without any link with gender or type of analgesia. Analysis of pain trajectories shown that these patients presented either higher initial pain at day 1 or positive slopes with worsening of pain.Acute postoperative pain is a risk factor of developing CPP. Identification of those people by pain trajectories can be useful to treat them early.

Risk factors for developing Persistent peri-incisional Chest Pain (PCP) after sternotomy are multiple. We examined whether hypoesthesia, hyperalgesia or dysesthesia, evoked in the postoperative period might be associated with PCP after sternotomy. One hundred patients undergoing a sternotomy were evaluated on day 5. Peri-incisional sensory testing was performed using von Frey filament. Presence and severity of PCP were assessed at 2 and 6 months. PCP was present in 29% and 15% of patients respectively at 2 and 6 months. Hyperalgesia on day 5 was present in 43% of patients with PCP at 6 months compared to 15% without PCP. Hypoesthesia was present in 57% of patients with PCP at 6 months compared to 22% without PCP. There was no significant difference in the incidence of dysesthesia. On day 5, hyperalgesia was correlated with a risk to develop PCP at 6 months. Among sensory abnormalities, the presence of hyperalgesia is associated with PCP at 6 months postoperatively.

Childbirth ranks among the most intense experiences of acute pain. Neuraxial analgesia (i.e. epidural or combined spinal-epidural technique) is the most effective way to relieve that pain but it is contraindicated or impossible to perform for some parturients. We designed a survey of the current use of analgesic alternatives to epidural analgesia (EA) for labor pain, specifically the use of opioid patient-controlled intravenous analgesia (PCIA), in the French part of Belgium (Wallonia and Brussels). A questionnaire was mailed to the departmental chair of the hospitals with an obstetric unit, both in university and non-university centers (total of 53 centers). The questionnaire evaluated the availability of EA, the alternatives used when EA was contraindicated, the use of opioid-based PCIA for labor analgesia as well as opioid preference and doses, and finally the reasons for not using opioid PCIA. The response rate was 67.5% (36 centers). Among the responding hospitals, EA was available for 68% (range 25-85%) of labors and deliveries. When EA was not available or contraindicated, a parenteral opioid (piritramide, tramadol or pethidine) was proposed in 19% (7/36) of the centers, Entonox in 11% (4/36), a pudendal block by obstetricians in 28% (10/36) and non-pharmacologic alternatives (i.e. hypnosis, sophrology, baths and massages) in 19% (7/36). In 28% (10/36) of the centers however, no analgesic alternative was proposed. Opioid PCIA was employed in 36% (13/36) of the centers and for an additional 11% (4/36) only in case of intrauterine death. Remifentanil was the first choice (76.5% of the PCIA), followed by sufentanil (23.5%). Other opioids (piritramide, morphine, fentanyl) and ketamine were also administered by PCIA. Forty-five percents of the centers reported never using opioid PCIA by either lack of knowledge (7%), fear of maternal or fetal side effects (48%) and unability to provide a correct supervision of the parturient during PCIA use (48%), opposition from the pediatricians or obstetricians (17%) or because they considered the technique as ineffective to relieve labor pain (17%). In conclusion, the survey demonstrated that, when EA is contraindicated, systemic opioid administered by PCIA is used in almost half of the centers (47%) and that remifentanil is the first choice, particularly when a live birth is expected.

The use of intraoperative multimodal analgesia has clearly improved postoperative pain control, mortality and morbidity after major surgical procedures. However, very few clinical trials have studied the longterm impact of intraoperative epidural or spinal analgesia on chronic postsurgical pain (CPSP) development. Even less studies have evaluated the modulatory effect of intraoperative neuraxial analgesia on objective changes (i.e. mechanical hyperalgesia) reflecting central sensitization.The present work compares general anesthesia alone (GA group) versus general anesthesia combined to either intraoperative epidural analgesia (EPID group: combination of bupicavaine, sufentanil and clonidine 1 microg/kg) or spinal analgesia (IT group: either bupivacaine or clonidine 300 microg) on the development of secondary mechanical hyperalgesia and the incidence of CPSP after major abdominal surgery. Data analyzed in the present work involve adult patients undergoing surgical resection of rectal adenocarcinoma who participated in three previously published randomized trials.Intraoperative epidural and particularly spinal analgesia reduced both incidence (p0.05 between GA alone and spinal analgesia) and extent (area) of secondary mechanical hyperalgesia surrounding the wound at 48h and 72 h after surgery. The use of intraoperative epidural and spinal analgesia also reduced CPSP incidence. Postoperative area of mechanical hyperalgesia seems positively correlated with the incidence CPSP.An effective intraoperative neuraxial block of nociceptive inputs from the wound using multimodal analgesia--specifically when involving spinal analgesics and antihyperalgesic drugs--contributes to prevent central sensitization and hence reduces CPSP after major abdominal procedures.

Hip fracture is a common pathology in elderly patients. Intercurrent diseases, mainly cardiac and respiratory, often result in significant morbidity and mortality. Anesthesia for hip fracture can be provided by general or regional techniques. The combination of a lumbar plexus and posterior sciatic nerve block represents an alternative to neuraxial technique of anaesthesia such as spinal anesthesia (4, 6). We report a case of acute toxicity resulting in the injection of local anesthetics Ropivacaine and Mepivacaine in elderly patient. An elderly woman was scheduled for surgical repair of a fractured femur neck by dynamic hip screw synthesis. Anesthesia was realized by peripheral nerve bi-block (lumbar plexus and posterior sciatic block) (7). The patient experienced seizures and dysrhythmias twenty minutes after block completion and injection of the anesthetic solution [Ropivacaine 0.75%, administered for lumbar plexus block performed via the posterior approach (WINNIE) and Mepivacaine 1.5%, administered for posterior sciatic nerve block (LABAT)]. Cardiopulmonary resuscitation was successful. All signs of toxicity disappeared after injection of midazolam and atropine, intubation and 100% oxygen ventilation. We decided to proceed with surgery. The postoperative course was uncomplicated and made a full recovery.

The aim of this study was to evaluate the association of a small dose of intrathecal ropivacaine with small doses of intrathecal clonidine for ambulatory surgery.One hundred twenty patients, classified as American Society of Anesthesiologists physical status I and scheduled for knee arthroscopy, were studied. Patients were randomly assigned to receive 4 ml of one of the following double-blinded isobaric intrathecal solutions: 8 mg of ropivacaine (group 1; n =30); 8 mg ropivacaine plus 15 microg clonidine (group 2; n =30); 8 mg ropivacaine plus 45 microg clonidine (group 3; n =30); and 8 mg ropivacaine plus 75 microg clonidine (group 4; n =30). The level and duration of sensory anesthesia were recorded, along with the intensity and duration of motor block. Patient and surgeon were interviewed to evaluate the quality of anesthesia.Intrathecal ropivacaine (8 mg alone) produced short sensory anesthesia and motor blockade (132 +/- 38 min and 110 +/- 35 min; mean +/- SD). However, the quality of anesthesia was significantly lower than in any other group (P0.05). Ropivacaine (8 mg) plus 75 microg clonidine produced significantly longer sensory and motor anesthesia (195 +/- 40 min and 164 +/- 38 min; P0.05). However, this was associated with systemic effects, such as sedation and reduction of arterial blood pressure. Ropivacaine (8 mg) plus 15 microg clonidine did not prolong sensory or motor blockade, afforded high quality anesthesia, and was not associated with detectable systemic effects.Small-dose intrathecal clonidine (15 microg) plus 8 mg intrathecal ropivacaine produces adequate and short-lasting anesthesia for knee arthroscopy.

To evaluate the impact of standardized operative and peri-operative care on the outcome of liver transplantation in a single center series of 395 adult patients.Between February 1984 and December 31, 1998, 451 orthotopic liver transplantations were performed in 395 adult patients (or = 15 years) at the University Hospitals St-Luc in Brussels. Morbidity and mortality of the periods 1984-1990 (Gr I--174 pat.) and 1991-1998 were compared (Gr II--221 pat.). During the second period anti-infectious chemotherapy and perioperative care were standardized and surgical technique changed from classical orthotopic liver transplantation with recipients' vena cava resection (and use of veno-venous bypass) towards liver implantation with preservation of the vena cava (without use of bypass). Immunosuppression was cyclosporine based from 1984 up to 1996 and tacrolimus based during the years 1997 and 1998. Immunosuppression was alleviated during the second period due to change from quadruple to triple and even double therapy and due to the introduction of low steroid dosing and of steroid withdrawal, once stable graft function was obtained. Indications for liver grafting were chronic liver disease (284 pat--71.9%), hepatobiliary tumor (52 pat--13.2%), acute liver failure (40 pat--10.1%) and metabolic disease (19 pat--4.8%). Regrafting was necessary because of graft dysfunction (21 pat), technical failure (12 pat), immunological failure (18 pat) and recurrent viral allograft disease (5 pat); three of these patients were regrafted at another institution. Follow-up was complete for all patients with a minimum of 9 months.Actuarial 1, 5 and 10 years survival rates for the whole group were 77.9%, 65.7% and 58.3%. These survival rates were respectively 77.3%, 69.7%, 62.5% and 73.2%, 59.6% 51.4% for benign chronic liver disease and acute liver failure; those for malignant liver disease were 80.6%, 44.3% and 36.7%. Early (3 months) and late (3 months) posttransplant mortalities were. 14.4% (57 pat) and 21.2% (84 pat). Early mortality lowered from 20% in Gr I to 9.4% in Gr II (p0.02); this was due to a significant reduction during the second period of bacterial (99/174 pat.--56.9% vs 82/221 pat.--37.1%), fungal (14 pat.--8% vs 7 pat.--3.2%) and viral (87 pat.--50% vs 49 pat.--22.2%) infections (p0.05) as well as of perioperative bleeding (92 pat.--52.9% vs 39 pat.--17.6%--p0.001). Late mortality remained almost identical throughout the two periods as lethal outcome was mainly caused by recurrent allograft diseases, cardiovascular and tumor problems. Morbidity in these series was important considering that almost, half of the patients had a technical complication, mostly related to bleeding (131 pat--33.2%) and biliary problems (66 pat--16.7%). Retransplantation index was 1.1 (54 pat.--14%). Early retransplantation mortality was 24%; it lowered, although not yet significantly, during the second period (8/25 pat.--32% vs. 5/29 pat.--17.2%).Despite a marked improvement of results, liver transplantation remains a major medical and surgical undertaking. Standardization of operative and perioperative care, less haemorraghic surgery and less aggressive immunosuppression are the keys for further improvement.