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Advances in pain management, new focus greatly easing postoperative pain

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PITTSBURGH (AP) _ All Deborah Keibler knew about hip replacement surgery was the long scar she had seen down the side of her grandmother's body. But when her doctor said the traditionally painful procedure could cure the limp in her right leg, the 49-year-old knew she didn't have a choice.

To her surprise, Keibler was able to leave the hospital the same day as her operation and had so little pain she didn't even need prescription painkillers.

Her hip was replaced through ``keyhole'' surgery _ with miniature instruments through tiny incisions _ and she was given a regional nerve block in her back instead of general anesthesia.

``For the vast majority of patients undergoing surgery, experiencing postoperative pain is not a must,'' said Dr. Jacques Chelly of the anesthesiology department with the University of Pittsburgh School of Medicine.

In fact, some experts say pain-free surgery is not so far off.

Doctors say patients timid about having surgeries for fear of pain shouldn't put it off: A new focus on patient comfort and advances in pain management are making many procedures nearly pain-free.

Interest in controlling postoperative pain has exploded in the past five years, said Dr. Barry Cole, director of education for the American Academy of Pain Management, a 6,000-member organization that teaches pain management techniques.

``What we've really come to begin to understand is, you could get conceivably close to pain-free surgery, without necessarily causing the patient any more surgical risk,'' Cole said.

Anesthesia has been a great tool to keep a patient asleep, immobile and out of pain during complicated surgeries. But once someone wakes up, anesthesia does little to curb the pain caused by cutting into the body, he said.

Charlene Hill, a spokeswoman for the Joint Commission for the Accreditation of Healthcare Organizations, said treating pain helps allay patients' fears about surgery, means less time for recovery and cuts health care costs. In 2001, the hospital accreditation agency adopted standards saying every patient should have the right to have pain assessed and treated.

The University of Pittsburgh Medical Center opened a pain center last year that deals with both chronic and surgical pain. One of its surgical techniques is a nerve block, an injection that block pain in a particular region of the body. It is being used during surgery and increasingly for postoperative pain management as well, allowing a decrease in morphine and other drugs whose side effects can slow recovery.

For Keibler's hip replacement, for example, the nerve block enabled her to remain awake during surgery.

Chelly likens the nerve blocks to the Novocain dentists use to deaden a small area in the mouth. Nerve blocks have been around for years, but they are increasingly being employed for all sorts of surgeries. UPMC uses them in total knee and hip replacements, shoulder surgeries, removal of tumors from the leg and arm, breast surgeries, hernia repair and many other procedures.

Laparoscopy with its tiny incisions is also a breakthrough for many surgeries.

``If you don't have to cut this patient in half and you can do this with a small tube, it's certainly going to help at the end for treating the pain,'' said Chelly, a professor who is also director of orthopedic anesthesia and acute pain services at UPMC Shadyside.

Cole, a neurologist and psychiatrist, said controlling postoperative pain begins before the surgery starts and involves not only the surgeon, but often the anesthesiologist, nurses, nurse practitioners and even physician assistants.

``There's just no excuse for painful surgery, except maybe in cases of traumatic surgery,'' Cole said.

Dr. James Rathmell, an anesthesiologist and chairman of the committee on pain medicine for the American Society of Anesthesiologists, said patients increasingly prefer regional anesthesia such as nerve blocks. He said technology, such as the development of better needles, has led to more ways to deal with acute pain.

He cited knee replacement surgery as one of the best examples of improved pain management. The operation used to be incredibly painful, he said. Now, it can be done with a regional anesthetic.

``People really like to be awake, less sedated. They have less of the hungover feeling,'' Rathmell said. ``We should be able to control the pain in the vast majority of folks.''

Keibler said her Caesarean section and foot surgery were much more painful than the hip replacement, and the C-section required seven days in the hospital.

Before her hip surgery, she used to wear down the edge of her right shoe because of her limp. Now she has been riding a bike, walking on a treadmill and lifting weights.

``I really, really feel a thousand times better than I did,'' said Keibler.

The surgery left two small incisions, barely the width of a piece of thread. Keibler said her grandmother would be proud.
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