Postoperative pain control following extensive pelvic exenteration

In the March issue of Diseases of the Colon & Rectum, surgeons from Australia discuss postoperative pain control following one of the most extensive operations performed for pelvic cancer. In an era where many studies have shown that patients do better after surgery with use of lesser amounts of opioid pain medication, this can be particularly challenging in those patients who have taken a significant amount of pain medication before surgery. This is exactly what was shown in this study. In a group of 99 patients undergoing the very extensive procedure of pelvic exenteration, an operation in which all pelvic organs are removed usually for advanced rectal, gynecologic, or urologic cancers, one-third of patients were already taking opioid medications for pain control preoperatively. The investigators were able to show that it is more difficult to control pain during their hospital stay in these patients.

Citation: Lim JS, Koh CE, Liu H, Solomon MJ, Johnstone CSH. The price we pay for radical curative pelvic exenterations: prevalence and management of pain. Dis Colon Rectum 2018;61(3):314-319.

The authors proposed using different types of pain control, including regional nerve blocks in order to lessen the need for opioid medication in these patients, something that is being performed more and more frequently. Doctors Kopp and Lanier of the Mayo Clinic, in an outstanding accompanying editorial, put this article into perspective. They explain how such opioid-sparing techniques do not apply solely to patients undergoing this specific operation, but rather apply to many different types of surgery. With the current opioid epidemic, they emphasize the concept of drug stewardship and stress that the approach to pain management "must always respond to individual patient needs and cannot simply become formulaic." It is especially difficult to take care of patients who are already used to taking large amounts of pain medication. Multidisciplinary care is needed when these patients undergo surgical procedures.