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The Price We Pay for Radical Curative Pelvic Exenterations: Prevalence and Management of Pain

Lim, Jessica, Shao-Yeung, B.Med.1; Koh, Cherry, E., M.B.B.S. (Hons.), M.S., F.R.A.C.S.2,3,4; Liu, Hannah, M.D.3; Solomon, Michael, J., M.B. B.Ch., M.Sc., B.A.O., D.Med.Sc., F.R.A.C.S., F.R.C.S.I.2,3,4,5; Johnstone, Charlotte, S.H., M.B.B.Ch., F.A.N.Z.C.A., F.P.M.A.N.Z.C.A.1

Diseases of the Colon & Rectum: March 2018 - Volume 61 - Issue 3 - p 314–319
doi: 10.1097/DCR.0000000000001013
Original Contributions: Colorectal Cancer
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BACKGROUND: Pelvic exenterations are extensive surgical procedures for locally advanced or recurrent malignancies of the pelvis. However, this is often at the cost of significant morbidity due to perioperative pain, which has been poorly studied.

OBJECTIVE: This study aims to review perioperative pain management in patients undergoing pelvic exenteration.

DESIGN: This is a retrospective review of patients undergoing pelvic exenteration between January 2013 and December 2014. Data were gathered from medical records and a prospectively maintained database.

SETTING: This study was conducted at a single quaternary referral center for pelvic exenteration.

PATIENTS: Consecutive patients underwent pelvic exenteration at a single center.

INTERVENTIONS: Pelvic exenteration was performed in consecutive patients.

MAIN OUTCOMES MEASURES: Primary outcomes were the prevalence of preoperative pain, preoperative opiate use (type, dosage), and postoperative pain (verbal numerical rating scale). Secondary outcomes included the number of pain consultations and correlations between preoperative opiate use, length of stay, and extent of resection (en bloc sacrectomy and nerve excision).

RESULTS: Ninety-nine patients underwent pelvic exenteration. Sixty-one patients (61.6%) underwent major nerve resection and/or sacrectomy. Thirty patients (30%) required opiates preoperatively, with a mean daily morphine equivalent of 72.9 mg (SD 65.0 mg). Patients on preoperative opiates were more likely to have worse pain postoperatively and to require higher opiate doses and more pain consultations (9.3 vs 4.8; p < 0.001). Major nerve excision and sacrectomy were not associated with worse postoperative pain. By discharge, 60% still required opiate analgesia.

LIMITATIONS: Retrospective study design, the subjective nature of pain assessment because of a lack of valid methods to objectively quantify pain, and the lack of long-term follow-up were limitations of this study.

CONCLUSIONS: Perioperative pain is a significant issue among patients undergoing pelvic exenteration. One in three patients require high-dose opiates preoperatively that is associated with worse pain outcomes. Potential areas to improve pain outcomes in these complex patients could include increased use of regional anesthesia, antineuropathic agents, and opiate-sparing techniques. See Video Abstract at

1 Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia

2 Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia

3 SOuRCe (Surgical Outcomes Research Centre), Royal Prince Alfred Hospital, Sydney, Australia

4 RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia

5 Discipline of Surgery, Sydney Medical School, University of Sydney, Sydney, Australia

Funding/Support: Dr Koh is a current recipient of the Foundation for Surgery Fellowship, Royal Australasian College of Surgeons.

Financial Disclosure: None reported.

Presented at the Tripartite Colorectal meeting, Seattle, WA, June 10 to 14 2017; the meeting of the Australian and New Zealand College of Anaesthetists, Auckland, New Zealand, April 30 to May 4, 2016; and the meeting of the Australia New Zealand College of Anaesthetists NSW Winter Continuing Medical Education, Sydney, Australia, June 18, 2016.

Correspondence: Cherry E. Koh, M.B.B.S. (Hons.), M.S., F.R.A.C.S., SOuRCe (Surgical Outcomes Research Centre), PO Box M 157, Missenden Rd, Camperdown NSW 2050, Australia. E-mail:

© 2018 The American Society of Colon and Rectal Surgeons