Lymphocele results either due to trauma to lymphatic vessels or following a vein graft harvest (as observed in 10–16% of patients). When a lymphocele persists despite conservative treatment, patients may be subjected to undue distress. We report a case of successful treatment of an intractable lymphocele––which had been refractory to conservative treatment including stretch bandage, drainage and local injection for two years––after a great saphenous vein harvest, through lymphatic venous anastomosis (LVA). The lymphocele resolved shortly after LVA without any adverse effect. LVA can be a useful and minimally invasive alternative treatment for lymphocele after harvesting the great saphenous vein.

Supermicrosurgical lymphatic venous anastomosis for intractable lymphocele after great saphenous vein harvesting graft

Despite the harrowing opioid crisis in the United States, the use of opioids to combat musculoskeletal pain continues to be widespread. In the setting of hip arthroscopy, approximately one-third of patients are on opioids while awaiting surgery to address the pain that results from femoracetabular impingement syndrome. In addition, the use of opioids to address pain postoperatively is common practice. With the rapid rise of hip arthroscopy in the United States, it is paramount that other modes of pain relief are promoted by surgeons in conjunction with allied health professionals, such as physical therapists. In fact, early physical therapy has been shown to decrease the use of postoperative opioids by 10%. The use of complementary and alternative therapies should be common practice in the in the orthopaedic setting to assist in reducing the number of opioids used for both pre and postoperative pain management. While this may be a small piece of the opioid crisis puzzle, it is up to all of us in the medical community to do our part and change the direction of the current opioid crisis.

Editorial Commentary: Hip Arthroscopists Can Reduce Postoperative Opioid Use.

Lymphoceles result from either trauma to the lymphatic vessels or after vein graft harvest, which occurs in 10% to 16% of patients. When a lymphocele persists despite conservative treatment, patients can experience undue distress. We have reported the case of successful treatment using lymphatic venous anastomosis (LVA) of an intractable lymphocele that had been refractory to conservative treatment, including stretch bandaging, drainage, and local injection for 2 years after great saphenous vein harvest. The lymphocele resolved shortly after the LVA without any adverse effects. LVA can be a useful and minimally invasive alternative treatment of lymphocele after harvesting the great saphenous vein. 

Pain is an ancient medical complaint and a clinical riddle that has never been entirely solved. Looking back into history was the springboard to a look into the future of pain medicine. This article was based on a series of presentations given in a recent congress (May 2023) and represents the research, views, and opinions of the authors. Opium has been used for millennia to treat pain, but when it gained broad use in the United States in the 1980s and 1990s, it was so vastly overprescribed and mis-prescribed that it led to a public health crisis. This, in turn, led to the reaction where opioids at times were under-prescribed, leaving out many patients who may have benefited from opioids while leaving many legacy pain patients to manage withdrawal on their own and with few analgesic options. Cannabinoids (CB) were likewise widely used for various conditions, including pain, but were outlawed in the 20th century, only to be brought back as a potential analgesic agent. Interventional pain medicine is a developing discipline and has reinforced the concept of the interdisciplinary pain clinic. It plays an increasingly important part in modern medicine overall, especially with the support of ultrasound, for both diagnosis and therapy. Today, the views about pain have changed. Anyone has accepted that pain is not purely a physical phenomenon but a biopsychosocial phenomenon that occurs within a cultural context. Pain management remains a small but vitally important medical subspecialty that is critical from a functional enablement and population health perspective, which is helping to navigate new therapeutic targets, new drugs and routes of administration, greater understanding of pain psychology, and new technologies. Pain control today means early intervention, functional enablement through pain alleviation, educating patients about pain management, and minimizing the transition from acute to chronic pain. 

Looking Back, Moving Forward in Pain Medicine

Chylous ascites (CA) is an uncommon entity with several etiologies. Only a few cases of CA have been reported as a complication after liver transplantation (LT). Most of these cases occurred within 1 month after surgery and typically resulted from traumatic intraoperative injury leading to disruption of lymphatics. Although peripheral lymphedema has been frequently correlated with use of calcineurin inhibitors, associated spontaneous CA has only been reported in a few cases after renal transplantation. We report a case of delayed spontaneous CA after LT caused by the use of the mammalian target of rapamycin (mTOR) inhibitor everolimus. Everolimus was introduced in our patient early after transplantation because of tacrolimus-induced microangiopathy, and years later the patient presented with spontaneous CA. After excluding other causes of CA, everolimus was discontinued, and immunosuppression was maintained by increasing prednisone and continuing mycophenolate mofetil. Additionally, the patient was treated with percutaneous drain placement and began a low-fat, high-protein diet. One month later the patient had complete resolution of symptoms with no recurrence of ascites. To our knowledge, this is the first case of delayed-onset CA caused by everolimus after LT.

Spontaneous Chylous Ascites After Liver Transplantation Secondary to Everolimus: A Case Report.

Introduction Medical use and overuse of opioids have become an increasing problem over the past several decades Postoperative pain control is the strongest indication for the use of opioid analgesics Previous studies have demonstrated benefit from complementary and alternative therapy (CAT) for postoperative pain relief A prior study conducted by Riswold et al found that a unit staff training session on CAT improved patient experiences postoperatively following total joint replacement The study was limited in that it did not examine if there were any changes in opioid usage following this intervention Methods This study is a continuation of the Riswold et al study on CAT training intervention In July 2017, a four-hour staff training session on alternative comfort measures and pain medication administration took place Opioid administration data was extracted from the PYXIS software for all patients who had received more than three opioid administrations across their hospital stay in the three months prior to CAT training and the three months post-training Opioid administrations were converted to total oral morphine equivalents The pre- and post-intervention groups were compared using independent sample t-tests using SPSS software Results Statistically significant reduction of total oral morphine equivalents occurred following CAT training intervention (p=034, CI 276, 6981) Average oral morphine equivalents per day (p=0023, CI 126, 1657) and per administration (p=000048, CI 064, 225) also were significantly reduced following the CAT training intervention Conclusion This study strengthens the findings of prior studies, showing that CAT can improve patient satisfaction while also reducing overall opioid burden for post-surgical patients

Biopsychosocial Pain Management and its Effect on Postoperative Opioid Use.

White matter changes on MRI can be a diagnostic puzzle as a large group of inflammatory, autoimmune, infectious, and neoplastic conditions can present in this way. An otherwise healthy 36-year-old male presented with his second episode of unilateral weakness, the first episode occurring five years previously. He did not have sensory or cerebellar symptoms with the current or previous episode. He reported that his grandfather, father, two of his aunts, and an uncle had multiple sclerosis (MS), dying in their 40s-50s from their disease. The MRI during his first hospitalization revealed acute ischemia as well as diffuse white matter hyperintensities. The current MRI revealed new ischemic changes as well as progression of the white matter hyperintensities with notable temporal lobe involvement. While small vessel disease and multiple sclerosis can present similarly, the history of stroke, lesion distribution, and family history suggested an alternative diagnosis. Due to high clinical suspicion, genetic testing was performed for CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) and confirmed the diagnosis. This case report describes the approach to the adult with white matter changes and describes the typical presentation and findings of CADASIL, the most common heritable cause of stroke and vascular dementia in adults.

A Young Adult with White Matter Changes and Recurrent Stroke Symptoms.

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Spontaneous Chylous Ascites After Liver Transplantation Secondary to Everolimus: A Case Report.

Biopsychosocial Pain Management and its Effect on Postoperative Opioid Use.

A Young Adult with White Matter Changes and Recurrent Stroke Symptoms.