Objective: To examine the clinical significance of an opioid, tapentadol, for cancer pain relief including its analgesic effects and indications based on our clinical experience. Methods: We retrospectively studied 31 patients receiving tapentadol in our hospital. Results: In 19 successfully treated patients, the numerical rating scale (NRS) scores showed a significant decrease in pain, and the doses at the start and completion of administration were 73.7±25.6 mg (morphine equivalent dose: 30 mg or less) and 125±49.3 mg, respectively. Six successfully treated patients showed improvement of gastrointestinal symptoms. The results of the comparison between successfully and unsuccessfully treated patients suggested titration to be difficult in patients with mixture of somatic pain and neuropathic pain. Conclusion: Based on our clinical experience, we consider tapentadol to be easy to use during the introductory period after treatment with non-opioids or low-dose opioids.

Introduction: The opioid-to-methadone conversion ratio is not constant. Thus, exacerbation of pain associated with switching of these drugs is a concern. We report two cases in which methadone was introduced in combination with epidural block. Case 1: The patient was a 55-year-old man who complained of perineal pain due to recurrent colorectal cancer. Diagnostic imaging could not be performed because of severe persistent pain and breakthrough pain even under treatment with oral oxycodone 600 mg/day. Methadone administration (starting dose, 45 mg/day) was started in combination with continuous lumbar epidural block. The persistent pain mostly dissipated after an approximately 2-week treatment period with methadone 75 mg/day, making magnetic resonance imaging measurement possible. Case 2: The patient was a 62-year-old man who complained of pain in both lower limbs due to spinal metastasis of prostate cancer. Pain impairing body movement persisted even during treatment with oral oxycodone 300 mg/day. The pain was reduced by combination treatment with continuous lumbar epidural block and methadone (starting dose, 30 mg/day), making it possible to perform radiotherapy. At the time of discharge from the hospital while being treated with methadone 45 mg/day, the patient complained minimally of pain. Conclusion: Owing to epidural block, switching to methadone was achieved smoothly without exacerbation of pain.

Rectal tenesmus is a very uncomfortable symptom. Though antiarrhythmic drugs and nerve blocks have been proposed as a treatment for rectal tenesmus, none is well-established. We report a 68-year-old female who undertook surgery for uterine cervical cancer and underwent chemotherapy. She got a bilateral nephrostomy and bowel obstruction during the chemotherapy because of recurrence. She decided to stop chemotherapy and to receive palliative care. She had a symptom of rectal tenesmus, which was refractory to medications. The clinical sign was severe and uncomfortable, making her very nervous. We planned to treat the rectal tenesmus with a nerve block. A ganglion impar block was insufficient to remove the symptom, and the saddle block failed due to epidural lipomatosis. We finally succeeded in alleviating the sign with a neurolytic caudal epidural block. Relief of tenesmus made her hope to spend her final period at home. She could stay at home with her family for seven days before death without recurrence of the symptom. Though there is no report about the effectiveness of neurolytic caudal epidural block for rectal tenesmus, we consider the block appropriate for the symptom.

Background/Aims: Bispectral index (BIS) monitors process and display electroencephalographic data are used to assess the depth of anesthesia. This study retrospectively evaluated the usefulness of BIS monitoring during endoscopic ultrasonography (EUS). Methods: This study included 725 consecutive patients who underwent EUS under sedation with propofol. BIS monitoring was used in 364 patients and was not used in 361. The following parameters were evaluated: (1) median dose of propofol; (2) respiratory and circulatory depression; (3) occurrence of body movements; (4) awakening score >8 at the time; and (5) awakening score 2 hours after leaving the endoscopy room. Results: The BIS group received a significantly lower median dose of propofol than the non-BIS group (159.2 mg vs. 167.5 mg; p=0.015) in all age groups. For patients aged ≥75 years, the reduction in heart rate was significantly lower in the BIS group than in the non-BIS group (1.2% vs. 9.1%; p=0.023). Moreover, the occurrence of body movements was markedly lower in the BIS group than in the non-BIS group (8.5% vs. 39.4%; p<0.001). Conclusions During EUS examination, BIS monitoring is useful for maintaining a constant depth of anesthesia, especially in patients 75 years of age or older.