How to reduce pain after surgery

Studies suggests that many patients suffer moderate to severe pain after abdominal surgery.  Most surgeons would use opiates (morphine) as the main pain medication after surgery.  As some of you are aware, morphine (and other opiates) cause your bowel to be inactive and some experience severe nausea and vomiting.  At University Tennessee - West Clinic, we initiated a program to assess and reduce surgical pain.  

Instead of using morphine only, my team started our patients with IV acetominophen (Tylenol) and gabapentin BEFORE surgery.  During surgery, we inject local anesthesia to numb the incision even after patients asleep under general anesthesia.   After surgery, we give patients more acetominophen, gabapentin and ketorolac (intravenous form of drug similar to ibuprofen).  With this regimen, most of my patients reported tremendous pain reduction compared to just morphine alone (data unpublished yet).  Most of my patients experience minimal pain after abdominal surgery with this multimodalities pain control method.   Instead of staying 3-5 days in the hospital after cancer surgery, most of my patients now go home the next day.  Another good thing about using less morphine is they experience less nausea after surgery.

Please note that not all patients have relieved of their surgical pain completely.  But most of them are relieved to the point that most of them can go home one day after surgery.   When you go for surgery, consider asking your surgeon about multimodality pain control.   In the reference below, I included our paper that was published on how to do this.

Reference

Azari L, Santoso JT, Osborne SE.  Optimal Pain Management in Total Abdominal Hysterectomy.  Obstet Gyn Survey. 2013, 68 (3): 215–227

Should I keep my ovary when I about to get hysterectomy (surgery to remove uterus)?

In the case of pelvic cancer, your surgeon usually recommends a complete removal of uterus and ovaries as part of cancer surgery.    However, you may undergo hysterectomy for benign (non cancer) indications.   In this case, your surgeon may recommend preservation of your ovary/ovaries especially when you are young and without menopausal symptoms.

My patients often ask what would be their chances of having future surgery to remove the ovaries if they preserve them during the initial hysterectomy surgery for benign indications (heavy uterine bleeding, painful menstruation, uterine fibroid, etc).   A study published in May 2013 by Casiano evaluated this question.

The study compared the risk of oophorectomy (removal of ovary during hysterectomy) of 4,931 women in Olmsted County, Minnesota, who underwent ovary-sparing hysterectomy for benign indications (case group) between 1965 and 2002, with 4,931 age-matched women who did not undergo hysterectomy (referent group). The incidence of oophorectomy after hysterectomy is only 9.2% at 30-year follow-up and is only 1.9 percentage points higher than the incidence of oophorectomy in referent women with intact reproductive organs.

In other words, as you elect to keep your ovaries during your hysterectomy for benign reasons, you have 9.2% chance of being reoperated again to remove your ovaries in the next 30 years.  This is only 1.9% higher than women who never had hysterectomy needing to have their ovaries remove in the next 30 years.  

Some of you may just want to remove your ovaries during hysterectomy even when you are young and have no cancer for fear of ovarian cancer.  Do keep it in perspective that your ovaries have many benefits reducing risks of heart disease, dementia, osteoperosis, hot flushes, and others.   Thus, do discuss this important decision to remove or preserve your ovaries during hysterectomy with your surgeon.

Reference:

- Casiano ER, et al.  Risk of oophorectomy after hysterectomy. Obstet Gynecol. 2013;121(5):1069-74

- Parker WH, et al. Ovarian conservation at time of hysterectomy - the Nurses' health study.  Obstet Gynecol 2009; 113: 1027-37

Daily low dose aspirin to reduce cancer

Aspirin has been used for pain relief.  But several studies now documented that aspirin also reduces heart attack and cancer. It also has an increased risk of bleeding (stroke, bowel bleeding, etc).   A meta-analysis study suggests that aspirin use in 1000 average risk patients at age 60 years would be expected to result, over a 10-year period, in six fewer deaths, 19 fewer non-fatal myocardial infarctions, 14 fewer cancers, and 16 more major bleeding events.   

Sokol et al recommended for individuals age 50 years or older without excess bleeding risks to take daily aspirin at a dose of 75 to 100 mg. Patients who are risk or concern about bleeding may not want to do this.  Please discuss it with your doctors and practitioners. 

  

Reference

- Sokol NH. Practice changing updates.  Uptodates. Accessed 5-5-13

- Rothwell PM, et al.  Short-term effects of daily aspirin on cancer incidence, mortality, and non-vascular death: analysis of the time course of risks and benefits in 51 randomised controlled trials. Lancet. 2012;379(9826):1602.

Obesity and cancers

Some of my patients and family have asked me the effective way to reduce cancer.  As I searched extensive medical literature and the latest research, I found two most effective ways that we could control: stop smoking and achieves ideal body weight.   In addition to heart disease, joints problem, back pain, sleep apnea, diabetes, etc, obesity increases cancer risks in

• Esophagus
• Pancreas
• Colon and rectum
• Breast (after menopause)
• Endometrium (lining of the uterus)
• Kidney
• Thyroid
• Gallbladder

The mechanisms linking obesity and cancer are well described in the NCI websites:

• Fat tissue produces excess amounts of estrogen, high levels of which have been associated with the risk of breast, endometrial, and some other cancers.
• Obese people often have increased levels of insulin and insulin-like growth factor-1 (IGF-1) in their blood (a condition known as hyperinsulinemia or insulin resistance), which may promote the development of certain tumors.
• Fat cells produce hormones, called adipokines, that may stimulate or inhibit cell growth. For example, leptin, which is more abundant in obese people, seems to promote cell proliferation, whereas adiponectin, which is less abundant in obese people, may have antiproliferative effects.
• Fat cells may also have direct and indirect effects on other tumor growth regulators, including mammalian target of rapamycin (mTOR) and AMP-activated protein kinase.
• Obese people often have chronic low-level, or “subacute,” inflammation, which has been associated with increased cancer risk.

So, how do I lose weight.  Losing weight is hard but it is so worth it because you are worth it.   Please see my previous blog on weight loss.

Reference:

http://www.cancer.gov/cancertopics/factsheet/Risk/obesity

Blood thinner treatment in patients with blood clot and cancer

Patients with cancer are at higher risk to develop blood clot.  Blood clot in the leg is called deep venous trhormbosis and in the lung is called pulmonary emboli.  Clot is very serious and can be life threathening.  The treatment usually consists of giving patients blood thinner in the form of pills (Warfarin or coumadin) or injection (low molecular weight heparin such as dalteparin [Fragmin] or enoxaparin [lovenox]).

A multicenter, international, randomized clinical trial (CLOT trial) compared six months of treatment with either dalteparin or warfarin (target INR 2.0 to 3.0) in 672 patients with cancer and acute symptomatic blood clot. Dalteparin therapy was associated with a significant reduction in the cumulative rate of recurrent VTE at six months (9 versus 17 percent, hazard ratio 0.48, 95% CI 0.30-0.77). There were no significant differences in the rates of major bleeding (6 versus 4 percent), any bleeding (14 versus 19 percent), or overall mortality at six months (39 versus 41 percent) between the dalteparin and warfarin arms, respectively.  Dalterparin received approval to be used in patients with cancer and blood clot.  Please note that the patients who received coumarin in that study, only 46% were therapeutic coumarin leven, 30% were below and 24% were over the target coumarin level.

Another trial, the CANTHANOX trial compared three months of therapy with either warfarin or enoxaparin in cancer patients with bloot clot.  After 147 patients were accrued, the study concluded that warfarin was associated with a high bleeding and enoxaparin may be as effective as and safer than warfarin.

A 2008 Cochrane review of results in six randomized controlled trials in cancer patients receiving long-term treatment for VTE found no survival advantage for LMW heparin over warfarin and no difference in bleeding outcomes, but a significant reduction in VTE.

My experience show that not too many patients want to inject themselves for 3-6 months and prefer pill warfarin.   But you should discuss the pro and con with your oncologists of these 2 drugs if you have cancer and blood clot.

Reference

Lee AY, et al.  Randomized Comparison of Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer (CLOT) Investigators. N Engl J Med. 2003;349(2):146.

Meyer G, et al. Comparison of low-molecular-weight heparin and warfarin for the secondary prevention of venous thromboembolism in patients with cancer: a randomized controlled study.  Arch Intern Med. 2002;162(15):1729.

Bauer KA.  Treatment of venous thromboembolism in patients with malignancy.  Uptodate.  Accessed 4-28-13

Akl EA, et al.  Anticoagulation for the long term treatment of venous thromboembolism in patients with cancer. Cochrane Database Syst Rev. 2008;