Lee Hayun, Kukreja Yuvraj, Niraj G
Specialty Trainee, Department of Pain Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK.
Advanced Pain Medicine Fellow, University Hospitals of Leicester NHS Trust, Leicester, UK.
Scand J Pain. 2023 Feb 13;23(4):712-719. doi: 10.1515/sjpain-2022-0090. Print 2023 Oct 26.
Post cholecystectomy pain syndrome can affect over a third of patients undergoing laparoscopic cholecystectomy. Acute exacerbations can result in recurrent emergency admission with excessive healthcare utilization. Standard surgical management appears to focus on visceral aetiology. Abdominal myofascial pain syndrome is a poorly recognised somatic pathology that can cause refractory pain in this cohort. It develops as a result of trigger points in the abdominal musculature. The report describes the pathophysiology and a novel interventional pathway in the management of post cholecystectomy pain secondary to abdominal myofascial pain syndrome.
The prospective longitudinal audit was performed at a tertiary pain medicine clinic in a university teaching hospital. Over a six-year period, adult patients with refractory abdominal pain following laparoscopic cholecystectomy were included in a structured interventional management pathway. The pathway included two interventions. Intervention I was a combination of abdominal plane blocks and epigastric port site trigger injection with steroids. Patients who failed to report durable relief (>50% pain relief at 12 weeks) were offered pulsed radiofrequency treatment to the abdominal planes (Intervention II). Outcomes included patient satisfaction, change in opioid consumption and impact on emergency visits.
Sixty patients who failed to respond to standard management were offered the pathway. Four patients refused due to needle phobia. Fifty-six patients received Intervention I. Failure rate was 14% (8/56). Forty-eight patients (48/56, 86%) reported significant benefit at 12 weeks while 38 patients reported durable relief at 24 weeks (38/56, 68%). Nine patients received Intervention II and all (100%) reported durable relief. Emergency admissions and opioid consumption were reduced.
Abdominal myofascial pain syndrome is a poorly recognised cause of post cholecystectomy pain. The novel interventional management pathway could be an effective solution in patients who fail to benefit from standard management.
胆囊切除术后疼痛综合征可影响超过三分之一接受腹腔镜胆囊切除术的患者。急性发作可导致反复急诊入院，医疗资源利用过度。标准的手术治疗似乎侧重于内脏病因。腹部肌筋膜疼痛综合征是一种未得到充分认识的躯体病理状况，可在该群体中引起难治性疼痛。它是由腹部肌肉组织中的触发点发展而来的。本报告描述了继发于腹部肌筋膜疼痛综合征的胆囊切除术后疼痛管理的病理生理学和一种新的干预途径。
在一所大学教学医院的三级疼痛医学诊所进行前瞻性纵向审计。在六年期间，将腹腔镜胆囊切除术后患有难治性腹痛的成年患者纳入结构化干预管理途径。该途径包括两种干预措施。干预措施I是腹部平面阻滞和上腹部端口部位触发点注射类固醇的联合应用。未报告持久缓解（12周时疼痛缓解>50%）的患者接受腹部平面的脉冲射频治疗（干预措施II）。结果包括患者满意度、阿片类药物消耗量的变化以及对急诊就诊的影响。
60例对标准治疗无反应的患者接受了该途径治疗。4例患者因针头恐惧症拒绝治疗。56例患者接受了干预措施I。失败率为14%（8/56）。48例患者（48/56，86%）在12周时报告有显著改善，38例患者在24周时报告有持久缓解（38/56，68%）。9例患者接受了干预措施II，所有患者（100%）均报告有持久缓解。急诊入院次数和阿片类药物消耗量减少。
腹部肌筋膜疼痛综合征是胆囊切除术后疼痛未得到充分认识的原因。这种新的干预管理途径可能是对标准治疗无反应患者的有效解决方案。
