title: Neurolytic sympathectomy in the management of cancer pain-time effect: a prospective, randomized multicenter study.
abstract: BACKGROUND
  Sympathectomy is currently used as the fourth step of the modified World Health Organization (WHO) analgesic ladder. Sympathectomy can be performed early, before the second step on the ladder.
  
  
  OBJECTIVE
  We hypothesized that early sympathectomy would reduce pain and opioid consumption and improve quality of life.
  
  
  METHODS
  One hundred nine patients, with inoperable abdominal or pelvic cancer, reporting visceral pain of 40-70 on a visual analogue scale and taking nonopioid analgesics were allocated randomly into two groups: either blocks were performed before Step 2 of the WHO ladder, then analgesics were managed according to the ladder (Group I) or analgesics were given according to the WHO ladder, and blocks were performed as the fourth step after failure of strong opioids to control pain (Group II). Visual analogue scale scores, responder analysis, daily opioid consumption, related side effects, and quality of life were assessed.
  
  
  RESULTS
  Responders were significantly higher in Group I (P < 0.0001), and partial responders and nonresponders significantly increased in Group II (P < 0.0001 and 0.006, respectively). Opioid consumption significantly decreased in Group I (P < 0.0001 during first 12 months and 0.007 at the last assessment time), with concomitant significant reduction in related side effects. The number of patients who had a good analgesic response on tramadol significantly increased in Group I during the first five months (P < 0.05). European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 global quality-of-life subscale scores revealed significant improvement until the fifth month in Group I (P < 0.05).
  
  
  CONCLUSIONS
  Sympathectomy before Step 2 on the WHO analgesic ladder seems to lead to better pain control, less opioid consumption, and better quality of life in cancer patients.
authors.affiliation: Departments of Anesthesiology and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta; Departments of Anesthesiology and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura City, Egypt. Electronic address: yasser.amr@gmail.com.
authors.forename: Yasser M
authors.initials: YM
authors.lastname: Amr
authors.affiliation: Departments of Anesthesiology and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta; Departments of Anesthesiology and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura City, Egypt.
authors.forename: Mohamed Y
authors.initials: MY
authors.lastname: Makharita
mesh_terms: D000008:Abdominal Neoplasms / Q000503:physiopathology*; D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000009:adverse effects / Q000627:therapeutic use; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000503:physiopathology*; D059408:Pain Management / Q000009:adverse effects / Q000379:methods*; D010147:Pain Measurement; D010386:Pelvic Neoplasms / Q000503:physiopathology*; D011446:Prospective Studies; D011788:Quality of Life; D011795:Surveys and Questionnaires; D013562:Sympathectomy / Q000009:adverse effects / Q000379:methods*; D014147:Tramadol / Q000627:therapeutic use; D016896:Treatment Outcome; D014944:World Health Organization
chemical_list: D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D014147:Tramadol
keywords: Early sympathectomy; WHO analgesic ladder; cancer pain