Therefore, we conducted this study to assess the occurrence of postoperative pain following open hemorrhoidectomy under local anesthesia versus saddle block for uncomplicated 3rd or 4th degree hemorrhoids. Pain severity was assessed at 2, 4 and 6 h post open hemorrhoidectomy using visual analogue scale (VAS). Data was analysed using SPSS version 26 at a p < 0.05 as statically significant using visual analogue scale (VAS).This was a prospective equivalence randomized, double blind controlled trial conducted from December 2021 to May 2022 among patients with primary uncomplicated 3p = 0.09) with a none significance by Kruskal–Wallis’s test (p:0.925).We recruited 58 participants in this study who underwent open hemorrhoidectomy under local anesthesia or saddle block (29 participants per group). The sex ratio was of 1.15 of female to male and a mean age of 39 ± 13. VAS was found to be different at 2 h post OH compare to other time of pain assessment but not statically significant by area under the cover (AUC) (95% CI = 486–0.773: AUC = 0.63; rd or 4th degree hemorrhoids. Close monitoring of pain in postoperative period is mandatory especially at 2 h to assess need of analgesia.Local anesthesia was found to be having a similar pain severity occurrence in post operative period among patients undergoing open hemorrhoidectomy for primary uncomplicated 3th October, 2021.Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 8 Hemorrhoids is the most prevalent anal disease with various management options as per the choice of patients and his surgeon which range from conservative treatment (dietary and sclerotherapy) to surgical methods like band ligation and excision according to the grade of hemorrhoids , 3. ConvAnorectal surgery requires adequate anesthesia due to its multiple nerve supply . PainfulControversial results have been published before as to the occurrence of pain following open hemorrhoidectomy under local anesthesia versus spinal anesthesia or general anesthesia. In the United Kingdom and in Brazil, studies found a similar mean pain scores in 10 days follow-up , 13 yet Despite the use of different anesthetic techniques, postoperative pain remains a major problem in up to 40% of patients during postoperative period , 16. In This study was a prospective equivalence double blind randomized controlled trial (RCT) conducted in the department of surgery at Kampala International University Teaching Hospital (KIU-TH), Kitagata and Ishaka Adventist Hospitals in Western Uganda. Patients were randomly assigned to either the local anesthesia group (A) or the saddle block group (B). Patients and outcome assessors were blinded about the anesthesia used.rd or 4th degree hemorrhoids and classified by American Society of Anesthesiologist (ASA) as I and II were included in this study.All patients admitted to the surgical ward for elective hemorrhoidectomy during the study period were considered as our population of the study. Patients aged 18–65 years with uncomplicated 3We hypothesized that the mean post-operative pain scores after hemorrhoidectomy using local anesthesia was not different from that done under saddle block. Using the formula for an equivalence design in randomized control trials by Zhong  and accoThe participants were allocated randomly to either the Local Anesthesia group (Group A) or the Saddle Block group (Group B) by using envelope allocation concealment whereby 58 envelops were obtained and inside them half of the envelopes was containing a chit with letter A while the other half was having a chit with letter B signifying local anesthesia and Saddle block respectively. This was then kept in a safe box whereby the participants were told to pick one envelope from the box at the time of surgery.th day postoperative. Diclofenac sodium 100 mg oral 8 hourly for five days was considered as rescue analgesia postoperatively. All patients were receiving tablet of Metronidazole 400 mg 8 hourly for the five post-operative days. Follow-up research assistants different from the recruiting team were collecting outcome data from patients at stipulated time and entering it into Microsoft Excel sheet up to the 7th day postoperative. Patients were called back for review and follow-up assessment. Those who were not be able to come back to the hospital after discharge were interviewed on a telephone call.The patients admitted for elective hemorrhoidectomy were undergoing pre-anesthetic evaluation the day before surgery and were given fasting guidelines including 6 h for solid foods and 2 h to anesthesia for clear fluids like water. All patients were receiving prophylactic antibiotics (Intra-venous 500 mg of metronidazole) 1 h before incision . All patp < 0.05 as statistically significant.Data was statistically analysed using IBM Statistics SPSS for Windows 23.0. The primary outcome analysed all randomized patients (on an intent-to-treat (ITT) basis) and per-protocol (PP) population. The mean pain scores at rest and their standard deviations were computed and compared using one-way ANOVA tests. VAS scale was stratified as ordinal and the significance in difference in mean scores between local and saddle groups determined by Kruskal–Wallis test at 95% Confidence interval, regarding 2) test of significance was used in order to compare proportions between qualitative parameters.Furthermore, the mean pain scores were further analyzed for significant differences in area under the curve (AUC) for VAS (2-sample t-test). Cross tabulation was performed and odds ratio computed for each technique of open hemorrhoidectomy. Chi-square  under the number KIU-REC-2021–24. After approval by the KIU-REC, the trial was registered with Pan African Clinical Trials Registry under the number PACTR 202,110,667,430,356 on 8The Consolidated Standards of Reporting Trials (CONSORT) diagram for patients’ recruitment is shown in the figure below. All the 58 patients recruited consecutively were randomized and followed up to day 7 post OH. The analysis did not have any missing data Fig. .Fig. 1CoAmong 58 patients who underwent surgery during this study, the mean age was of 39 ± 13 with a sex ratio of 1.15 of female to male. Peasant constituted the majority of our data. Most patient were classified as ASA I and had hemorrhoid grade 4 (Table p = 0.05) but not statistically significant at 4, 6 h and on 7 post operative day (p > 0.05) (Table The mean VAS was significantly higher at 2 h (2.28 ± 1.31) in the group A compare to group B (p = 0.09) (Table The area under the curve (AUC) on the Receiving Operating Characteristic (ROC) curve below is showing that there is no significant difference in occurrence of pain at 2 h in post-operative period among group A compare to group B (95% CI = 486–0.773: AUC = 0.63; rd or 4th degree hemorrhoids in three majors’ hospitals in rural western Uganda. To realize this comparison, we assessed the occurrence of pain in post-operative time at 2, 4, 6 h and on 7th post-operative day in the two groups. Pain occurrence in post-operative period among patients undergoing open hemorrhoidectomy is a common problem reported worldwide and different techniques of anesthesia have been used to carry out the procedure to increase the duration of no pain post-operatively [The aim of this trial was to assess the occurrence of postoperative pain following open hemorrhoidectomy under local anesthesia versus open hemorrhoidectomy under saddle block for primary uncomplicated 3ratively , 7.During our RCT, despite the difference in occurrence of pain assessed with VAS in post OH in the two groups of patients, the AUC has shown no difference in VAS assessment in post OH in both groups. These findings are confirming the null hypothesis of this RCT that no difference between the use of LA versus SB for OH in our area. The above findings are similar to the finding in UK where Kushwaba et al.  found ouHowever, our result is different to the finding of , 2 in InWith this data reported worldwide, there is no doubt that the use of local anesthesia is effective for open hemorrhoidectomy and that the occurrence of pain cannot hinder the applicability of this technique for patients with third- or fourth-degree hemorrhoid planned for OH as shown in a newly meta-analysis .rd or 4th degree hemorrhoids in three majors’ hospitals in rural western Uganda. Therefore, it is providing evidence about the use of local anesthesia for uncomplicated 3rd or 4th degree hemorrhoids open surgery in limited setting where few anesthetic providers exist like in Uganda. In addition to that, using VAS and analyzing the result by AUC increase the validity of the findings from this trial. With a sample size of 29 per arm but according to Ellen [This is the only study assessing the occurrence of post-operative pain following open hemorrhoidectomy under local anesthesia versus open hemorrhoidectomy under saddle block for primary uncomplicated 3to Ellen , a samplrd or 4th degree hemorrhoids. A close monitoring of pain in postoperative time is mandatory especially at 2 h to assess need of analgesia. There is a need to update the guideline of management of third- and fourth-degree hemorrhoid in low-income countries like Uganda on the use of local anesthesia for open hemorrhoidectomy for uncomplicated third- and fourth-degree hemorrhoid.We found that the use of local anesthesia has a similarity of pain occurrence in post operative period among patients undergoing open hemorrhoidectomy for primary uncomplicated 3


IntroductionMyofascial pain is defined as pain arising primarily in muscles and associated with multiple trigger points. Among the non-pharmacological methods, trigger point injection and electrotherapy are effective methods to treat myofascial pain syndrome. This study compares the effectiveness of dry needling (DN) and transcutaneous electrical nerve stimulation (TENS) in reducing cervical pain intensity and improving cervical range of motion in patients with neck pain due to myofascial trigger points.MethodsFifty patients were enrolled and randomized into two groups. Patients in group A received dry needling, and those in group B received TENS. Patients were evaluated using the Visual Analog Scale (VAS), Neck Disability Index (NDI), and Cervical Range of Motion (CROM) before the treatment and on days 14 and 28 after the treatment. The unpaired t-test was used to evaluate quantitative data, except for VAS, where the Mann-Whitney U test was used. All quantitative variables had a normal distribution with a standard deviation except for pain intensity (VAS), which deviated from the normal distribution. The significance level was set at a P-value=0.05.ResultsBoth DN and TENS groups showed significant improvement in VAS, NDI, and CROM between days 0 and 28 (p=<0.001). The DN group showed greater improvements in pain intensity from day 0 to day 28 (p =<0.001). Between days 0 and 28, there was no discernible difference in NDI changes between the groups . Mixed results were obtained for CROM, with significant improvement of cervical flexion in the dry needling group (p=<0.008) and significant improvement of cervical rotation to the painful side in the TENS group (<0.001).ConclusionBoth dry needling and TENS are effective in reducing pain and improving NDI and CROM in patients with neck pain due to myofascial trigger points. However, as dry needling is more effective in pain reduction, a single session of dry needling is more beneficial and cost-effective as compared to multiple sessions of TENS. Nonspecific neck pain (NSNP) is a common painful cervical spine disorder that affects 30%-50% of the general population, with about 10% of these patients experiencing chronic neck pain . MTrPs cThis study aimed to compare the effectiveness of dry needling and TENS in treating neck pain due to myofascial trigger points of the upper trapezius. This randomized controlled clinical trial was done at the Department of Physical Medicine and Rehabilitation in a tertiary care center in northern India. The period of the study was from 20/07/2021 to 28/11/2022. A total of 50 subjects with neck pain who had at least one active trigger point (TrP) were recruited from our OPD. All the subjects received information about the purpose and examination involved in this study, and all the subjects signed written informed consent before enrollment in the study. All of the subjects were thoroughly examined. Subjects were randomized into two groups by using online software (stat trek random number generator table) . AllocatEthical clearance and trial registrationPatient enrollment began after approval by the institutional ethical committee (ref. no. 107th ECM IIB THESIS/P6). The study is registered with a clinical trial registry under the number CTRI/2021/07/034855.Inclusion criteriaConsenting patients with neck pain of at least one week duration, aged between 19 and 50 years, and having at least one active trigger point were included in the study.Exclusion criteriaPatients having fibromyalgia , having Sample size calculationThe sample size was calculated according to a similar study conducted by Santiago et al. . To achiMethodologyPatients with myofascial neck pain were randomized into two groups, each consisting of 25 patients. The group A received a single session of dry needling, and the group B received seven sessions of TENS therapy.Outcome measurementPatients were evaluated using a VAS , NDI (Neck Disability Index) score, and cervical range of motion measurement using the goniometry method before and at follow-up after the procedures. The VAS scale is a subjective, validated assessment scale for acute and chronic pain. Scores are measured on a 10-cm VAS scale line and are graded on a scale of 0 (no pain) to 10 (worst pain) . The NecInterventionThe diagnosis of the trigger point was made according to Travell and Simon’s criteria . SubjectGroup B, with 25 subjects, received TENS therapy, which was applied by a dual-channel portable machine with symmetric bi-phasic rectangular pulses with 100 micro sec duration and a current frequency of 60 Hz. The negative electrode was placed on the active myofascial trigger point of the neck muscle, and a positive one on the appropriate tendon insertion site. The total duration of the application was 20 mins per session, with a total of 14 sessions consisting of one session per day for two weeks. Sessions were given at the hospital.DN group patients were informed that they might experience post-needling pain and were instructed to apply ice fomentation every two hours for the first 48 hours. All subjects were telephoned 48 hours post-intervention to ensure that no adverse events occurred.All patients were provided with a home exercise program consisting of active range-of-motion exercises for the neck and stretching exercises for the neck and back muscles. The program consisted of three sessions, and each session consisted of a repetition of every motion 20 times .Follow-up and data analysisPatients were followed up on the 14th and 28th days following the interventions, and their VAS, NDI index score, and cervical range of motion by goniometry were observed at each follow-up visit. IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp. was used to examine the data. For the descriptive analysis of quantitative variables, the mean and standard deviation were used. The normality of the data was assessed by the Kolmogorov-Smirnov test. For differences between groups in NDI and cervical ROM, the unpaired t-test was used, while for pain intensity (VAS), the Mann-Whitney U test was carried out, and the significance level was set at P-value=0.05.th day (p= 0.008). The cervical extension was unaffected pre- and post-procedure. More significant improvement of painful side cervical rotation was observed in the TENS group as compared to the DN group after the 28th day (p=<0.001). No significant difference was noted between the groups for painful and non-painful side cervical lateral flexion.The mean age of the DN group was 29.16±7.12 years, while the mean age of the TENS group was 25.68±5.80 years. No significant difference was found in mean ages between the groups (p=0.064). The female-male ratio in the DN group was 52.0:48.0, while in the TENS group, the ratio was 56.0:44.0. No significant difference was found in the male-female proportion between the groups (p=0.777). The VAS of the DN group and the TENS group were compared on days 0, 14, and 28. A significant difference was found in mean VAS between the groups on days 14 and 28 Figure , Table 2With increasing stress and many other factors, the prevalence and clinical complications related to nonspecific neck pain are on the rise, especially in the working population . There aEffect on disability as measured by the neck disability indexOur study reports a significant improvement in the neck disability index (p<0.001) in both groups at all follow-ups without a significant difference between the groups. This was in contrast to the study conducted by Santiago Garcia-de-Miguel et al. , which sEffect on painWe noted significant improvement in pain in both groups at all follow-ups, and a statistically significant difference between the groups was observed, with the DN group showing better improvement as compared to the TENS group (p<0.001). This was in contrast to the study conducted by Santiago Garcia-de-Miguel et al. , who notEffect on Cervical Range of Motion: Our study revealed significant improvement in cervical flexion at all the follow-ups, with a statistically significant difference between the groups by day 14 (p<0.008), wherein the dry needling group showed better improvement. However, by day 28, both groups revealed similar improvements. This contrasted with the study conducted by Santiago Garcia-de-Miguel et al. , in whicLimitationsOne of the limitations of this study was that participants were not blinded. As a result, there could be patient-related bias. However, patients were not given choices for selecting their treatment group. Moreover, the assessor was blinded to minimize the bias. The role of comorbidities on the outcome was not assessed in this study. In this study, we assessed and treated only the upper trapezius muscle, even though other muscles can also be involved in myofascial neck pain. A control (placebo) group to further assess the efficacy of dry needling and TENS was not included in our study. A sample size with only short-term follow-up was done in our study.Both dry needling and TENS are very effective methods to improve pain, neck disability index, and cervical range of motion in patients with myofascial neck pain. Both interventions have very good safety profiles and patient compliance. Dry needling took the upper hand in improving pain for ROM, but mixed results were obtained, with TENS having the upper hand in improving cervical flexion and cervical rotation towards the painful side. As dry needling is more effective in VAS reduction, a single session of dry needling is more beneficial and cost-effective as compared to multiple sessions of TENS; however, further studies with larger sample sizes and long-term follow-up are necessary to find and confirm the long-term efficiency of dry needling and TENS in myofascial neck pain.


Background and objectives: Bipolar electrocautery is commonly used to control bleeding after cold-instrument pediatric adenoidectomy, but the surgeon should be aware of the possible side effects. OBJECTIVE: The aim of our study is to investigate the effects of bipolar electrocautery when used for bleeding control at the end of an adenoidectomy procedure. Materials and Methods: We evaluated the effect of electrocautery on postoperative pain, velopharyngeal insufficiency symptoms, postoperative nasal obstruction, and rhinorrhea in a group of 90 children undergoing adenoidectomy in our ENT department over a period of 3 months. Results: After statistically analyzing the data, we found that the duration of postoperative pain, the duration of rhinorrhea and nasal obstruction, and the duration of painkiller administration, as well as the velopharyngeal insufficiency symptoms, were significantly longer in patients in whom electrocautery was used for hemostasis. A significantly higher incidence of posterior neck pain and halitosis  was noted in the patients in whom electrocautery was used for adenoidectomy hemostasis. Conclusions: Bipolar electrocautery use should be limited during pediatric adenoidectomy hemostasis because of the possible side effects: longer postoperative pain, prolonged nasal obstruction, rhinorrhea and velopharyngeal insufficiency, and halitosis. We noted some side effects that were specific to electrocautery use during adenoidectomy: posterior neck pain and oral malodor. Acknowledging the risk for these symptoms can help to alleviate the anxiety of both the parents and the patients regarding the expected postoperative outcomes. Adenoidectomy and tonsillectomy continue to be the most commonly performed procedures in pediatric ENT . DespiteThe endeavor to decrease postoperative pain and minimize the risk of postoperative hemorrhage has brought attention to novel adenoidectomy techniques and instrumentation. To date, different methods have been used to perform adenoidectomy: cold surgery, using the conventional curettage with a Beckmann curette or microdebrider or endoscopic-assisted adenoidectomy, and “hot methods”, with either bipolar electrocautery or radiofrequency (coblation) ,6. In 20Hemostasis after cold-instrument adenoidectomy is usually spontaneous, aided by the topical use of epinephrine solutions, antifibrinolytic agents (tranexamic acid), vasoconstrictors, hydrogen peroxide, saline solutions at different temperatures, or cold air flow by continuous aspiration ,7,8,9. IElectrosurgical units are a common form of electrical equipment in the operating theatre.In avoiding unnecessary damage to surrounding tissue, bipolar electrosurgery use seems better due to a more limited area of thermal spread compared with that of monopolar cautery ,10,11,12Monopolar cautery is rarely used during an adenoidectomy for adenoid mass removal and/or hemostasis ,14,15. MThe aim of our study is to investigate the effects of bipolar electrocautery and its specific side effects when used to control bleeding at the end of adenoidectomy procedures. The adenoidectomy procedure is performed in our department with cold instruments, with bipolar electrocautery applied locally only when spontaneous hemostasis fails. Written informed consent from all the parents of the children enrolled in this study, both for surgical treatment and for inclusion in this study, was obtained.We conducted an observational prospective study  on 90 consecutive pediatric patients undergoing adenoidectomy over a period of 3 months in our ENT department (November 2022–January 2023). From the number of children undergoing adenoidectomy in our operating theatre, two groups of patients were randomly selected: group A  and group B .Our hospital’s ethics committee approved this clinical study (no. 53792/12 December 2022).Initially, 100 randomly chosen children aged 0 to 18 years were enrolled in our study if they met the following inclusion criteria: 1—admission to the pediatric ENT department of M.S. Curie Children’s Hospital between November 2022 and January 2023 (on 2 randomly chosen days per week); 2—indication of adenoidectomy under general anesthesia with oral intubation ; 3—laboratory tests (blood markers), performed preoperatively by our hospital’s laboratory, showing no major coagulation abnormalities.All the surgical procedures that took place in the operating theatre were recorded in the surgical records saved in the hospital’s database. All the adenoidectomies were performed by 3 surgeons (consultants with over 20 years of pediatric ENT practice), using the same technique and the same type of instruments. Classical cold instruments were used in all the adenoidectomies (Beckmann’s steel curette with dimensions corresponding to the child’s nasopharynx). Adenoidectomy was performed with direct vision of the nasopharynx . Digital palpation of the adenoid mass and nasopharynx was routinely performed prior to and after the procedure in order to ensure complete excision of the adenoids. After complete resection of the adenoid mass, hemostasis followed the same steps: a cotton packing was introduced into the nasopharynx twice and left in place until soaked in blood, followed by one packing soaked with a vasoconstrictor agent (epinephrine dilution 1/10). Sometimes, direct irrigation with saline solution at room temperature, hydrogen peroxide applied locally, or cold air suctioning were used. In some patients with failure of hemostasis (considered as such in cases with over 10 min hemostatic time or the failure of the packing cottons to stop bleeding), bipolar electrocautery was used to complete the hemostasis; these patients were enrolled in group A. In our department, we use bipolar electrocautery for hemostasis after adenoidectomy; so, the present study refers to its use during the procedure. After surgery, the children went to the postoperative intensive care unit for 20 min monitoring; then, they returned to the clinical ward when stable, when there was no bleeding, and were able to start the oral intake of clear liquids. Early oral intake was encouraged.The parents of the patients in both group A and group B were given questionnaires  at the dFor pain assessment in small children (under 4 years of age), the parents were advised to use a visual analogue scale with happy/sad faces, drawn on the back of the questionnaires, when necessary, in addition to their behavioral assessment of the child’s wellbeing during their first few postoperative days. The responses were registered as a Yes/No answer; the precise grading of pain intensity was not taken into account in order to eliminate the bias resulting from the subjectivity of the children’s caretakers.It is important to mention that in the first question of the questionnaire, postoperative pain refers to odynophagia and/or retronasal pain, while the question “was there any neck pain/posterior headache?” specifically refers to the pain the patients feel at the back of their head; this is the pain which is referred from the adenoid area to the posterior neck region. Ear pain after adenoidectomy is also referral pain.t-test and the Pearson chi-squared test with Yates continuity correction were used to compare the results between the two groups; a value of p ˂ 0.05 was considered statistically significant.All the variables from the questionnaires were entered into an Excel database . In this study, the size of the adenoid mass was not graded or taken into account. The patient records were anonymized and analyzed. Statistical analysis was performed using the R project for statistical computing (R version 4.1.3); the Welch two-sample The Welch two-sample t-test was used to compare the variables between the two groups—group A  (electrocautery group) and group B (45 patients with spontaneous post-adenoidectomy hemostasis) (no electrocautery group). In all the patients, adenoidectomy was performed with cold steel instruments; bipolar electrocautery, if any, was used during hemostasis only in the children from group A.p = 0.925); thus, the groups were similar and comparable. Group A consisted of 24 girls and 21 boys, while group B consisted of 15 girls and 30 boys (33% girls and 66% boys).In the analysis of the patients’ age, the mean age and distributions were similar between the two groups—the mean age in group A was 4.69 years (1–16 years), and in group B, it was 4.73 years (1–12 years); the difference was not statistically significant (p < 0.001)  was 4.62 days (1–14 days), while in group B it was 2.13 days (with variations between 1 and 7 days). The difference was statistically significant (< 0.001) .p = 0.044)  and 3.16 days for the patients in group B (no electrocautery). The difference was statistically significant (= 0.044) .p = 0.015)  and 1.98 days for those in group B (without electrocautery). The difference was statistically significant (= 0.015) .p < 0.001) , there was a statistically significant difference between the groups. The mean duration of velopharyngeal insufficiency was 3.71 days for the patients in group A (electrocautery) and 1.64 days for the patients in group B (no electrocautery). The difference was statistically significant (< 0.001) .p < 0.001. Postoperative halitosis was encountered more frequently in the patients in whom electrocautery was used intraoperatively  encountered in the patients in group A (31 out of 45 patients) to that of the patients in group B (1 out of 45 patients), there was a statistically significant difference between the groups  (In comparing the frequency of postoperative ear pain encountered in the patients from group A (6 out of 45 patients) to that of the patients in group B (4 out of 45 patients), the difference between the groups was not statistically significant  .p < 0.001). Postoperative neck pain (pain at the back of the child’s head) was more frequently encountered in the patients in whom electrocautery was used intraoperatively (In comparing the frequency of postoperative posterior headache (neck pain) encountered in the patients from group A (34 out of 45 patients) to that of the patients in group B (2 out of 45 patients), there was a statistically significant difference between the groups . At the same time, the postoperative antialgic medication need was also significantly prolonged by cautery use in adenoidectomy (3.96 days for the patients in the electrocautery group compared to 3.16 days for the patients in the group without it).As with the findings in other literature reports ,24,25,26A possible hypothesis to explain the exacerbation of postoperative pain after electrocautery use in adenoidectomy can be found in the literature. Most authors agree that electrosurgical incisions appear to produce more inflammatory responses and tissue destruction compared to cold-cut wounds ,12,17. TTemporary velopharyngeal insufficiency is a well-recognized, yet rare, complication of adenoidectomy ,27,28. IHalitosis  is another possible complication of adenoidectomy, especially when using electrocautery ,28,29. OOur study noted that postoperative malodor is more frequently found (68.89%) in patients in whom bipolar cautery has been used and that it can persist postoperatively for up to 10 days. Our results are consistent with the other published data ,28,29.According to some authors, all electrosurgical lesions demonstrate some areas of desiccation, coagulation, and carbonization, regardless of the power or the waveform used ,19. The p > 0.05). We can conclude that ear pain is not specific for electrocautery use during the first days following adenoidectomy.Ear pain (earache) is sometimes mentioned by different authors as a possible consequence encountered after adenoidectomy (or tonsillectomy) ,24. As mp < 0.05); we can conclude that postoperative neck pain is more frequently found in patients in whom electrocautery was used for hemostasis. These findings are consistent with those of other literature reports [The presence of a posterior headache  is frequently mentioned by some authors after electrocautery adenoidectomy ,22,25,28 reports ,22,25,28According to our results, neck pain and the presence of halitosis are quite specific for electrocautery used to control bleeding at the end of adenoidectomy  . Griesel’s syndrome  is a rare but possible occurrence in adenoidectomy children ,21, but Knowing that symptoms of pain, malodor, and nasal obstruction are expected to persist longer in patients in whom cautery is used, we can recommend analgesics and nasal vasoconstricting agents for up to 5 or 7 days , and we can advise the parents of these children that oral malodor and posterior neck pain are possible occurrences.Many studies compare the results of cold (curettage) adenoidectomy to electrocautery or radiofrequency adenoidectomy (this means the ablation of the adenoid mass using bipolar electrocautery or radiofrequency coagulation—aspiration). Most of the authors agree that the operative time and blood loss are significantly reduced in the case of cautery use ,6. ThereAdenoid regrowth was reported by some authors to have a lower incidence after electrocautery adenoidectomy (2.8%) compared to the reported 5.4% after cold adenoidectomy . Our stuA study of 15,734 patients found the incidence of secondary hemorrhage after adenotonsillectomy to be 2.8 times higher after cold dissection plus bipolar hemostasis, 3.2 times higher after coblation, and 4.3 times higher after diathermy scissors, compared to cold technique . No primMost authors state that the degree of tissue damage from electrocautery depends on the duration of the energy applied, the power level used, and the tissue properties (vascular density and fat content) ,19. ThesStudies performed on fresh cadavers using a thermistor to evaluate temperature changes in the prevertebral fascia after electrocautery use during adenoidectomy (30 Watts for a period of 30 s—a relatively short period of time) show peak readings averaging up to 74 °C (with mean temperatures of 51.8 °C) . We can The present study might have some limitations. The fact that the study was based on a single-center experience and that only the side effects occurring in the first 2 weeks were taken into account  may have skewed the results in unpredictable ways. The dimension of the sample of patients enrolled may seem limited, but there were enough data to be statistically analyzed and to generate possible conclusions. The difficult communication with small children  could account for the inaccuracies in assessing the question “For how long did the pain last postoperatively?”, even though a visual analogue scale was used for smaller children ,32,33,34Bipolar electrocautery should be used with caution during adenoidectomy hemostasis. Electrocauterization stops bleeding during adenoidectomy but produces swelling, oedema, and significant pain after surgery, along with prolonged postoperative pain, prolonged rhinorrhea and nasal obstruction, prolonged velopharyngeal insufficiency symptoms, and a prolonged need for analgesic medication. The presence of oral malodor and neck pain were noted in the children in whom electrocautery was used for hemostasis during adenoidectomy. Understanding these symptoms can help in providing advice for parents of adenoidectomy children on the possible expected outcomes and to reduce the anxiety of both the child and his/her parents during the postoperative period.


Despite standard medical treatment endometriosis is often associated with disabling pain and poor quality of life (QoL). Studies indicate that psychological interventions (PIs) may improve pain and QoL, yet studies on the effects of PIs for women with endometriosis are sparse and limited by low-quality study designs. Therefore, this study aimed, in a rigorous three-armed design, to evaluate the effect of PIs on chronic pelvic pain (CPP) and QoL in women with endometriosis.This three-armed parallel, multi-center randomized controlled trial included fifty-eight endometriosis patients reporting severe CPP [≥ 5 for pain intensity measured on a 0–10-point numeric rating scale (NRS)]. Patients were randomly assigned to (1) Specific mindfulness- and acceptance-based psychological intervention (MY-ENDO), (2) Carefully matched non-specific psychological intervention (Non-specific), or (3) A wait-list control group (WL). The primary outcome was pelvic pain intensity/unpleasantness measured on NRS. Secondary outcomes included endometriosis-related quality of life, workability, pain acceptance, and endometriosis-related symptoms. Differences in outcomes between groups at post-treatment follow-up were analyzed using mixed linear models. Analyses were performed on an intention-to-treat basis.Compared to WL, psychological intervention (MY-ENDO + Non-specific) did not significantly reduce pain. However, psychological intervention did significantly improve the QoL-subscales ‘control and powerlessness’, ‘emotional well-being’, and ‘social support’ as well as the endometriosis-related symptoms ‘dyschezia’ and ‘constipation’. MY-ENDO was not superior to Non-specific.Women with endometriosis may have significant and large effects of psychological intervention on QoL despite an ongoing experience of severe CPP.12 April 2016, clinicaltrials.gov (NCT02761382), retrospectively registered. It can lead to disabling pelvic pain and poor quality of life. The traditional treatments for painful endometriosis consist of medical and/or surgical treatment. However, these treatments are, in many cases, insufficient in relieving the pain and improving the quality of life of these women. This study aimed to examine whether a psychological treatment can improve pain and quality of life in women suffering from painful endometriosis. In addition, the study examines whether The study demonstrated that psychological intervention does not lead to pain reduction in women with endometriosis. However, it significantly improved the quality of life of these women despite an ongoing experience of severe chronic pelvic pain. It also improved the endometriosis-related symptoms “constipation” and “pain during defecation”. Therefore, the study indicates that psychological intervention may be an appropriate strategy to manage symptoms and improve the quality of life in women with endometriosis, but a definitive decision on the preferred psychological modality  cannot be made. More research is needed before we can conclude whether one specific psychological intervention is to be preferred to best manage symptoms and improve the quality of life in women suffering from painful endometriosis.Endometriosis is a chronic and often painful gynecological disease defined as the presence and growth of endometrium-like tissue outside the uterus, usually in the pelvis, where it causes bleeding, inflammation, and adhesions . The estCurrent standard treatment for painful endometriosis includes hormonal treatment, pain medication, and/or surgical resection of endometrial lesions. Despite such treatment, recurrence and development of chronic pain problems are frequent –21. As pConsequently, we conducted a three-armed RCT to test the effects of (1) a specific PI (MY-ENDO), (2) a matched non-specific PI (Non-specific) and (3) a waitlist control (WL) on CPP and QoL in women with endometriosis. The hypothesis was to find statistically significant improvements in CPP and a number of secondary outcomes for (1) PI (MY-ENDO + Non-specific) compared to WL and for (2) MY-ENDO compared to Non-specific.Patients were randomly assigned to one of three conditions: (1) A specific mindfulness- and acceptance-based PI called “Mind Your ENDOmetriosis” (MY-ENDO), (2) A non-specific PI (Non-specific) that matched MY-ENDO in non-specific factors such as empathy, the therapeutic alliance, a cogent rationale, and expectations of improvement, but did not include the assumed specific ingredient, mindfulness or (3) A WL that involved treatment, as usual, to control for the natural fluctuations in pain . ParticiThe study was preregistered with The Danish Data Protection Agency , approved by The Central Denmark Region Committees on Health Research Ethics (registration no. 1-10-72-138-15), and retrospectively registered at clinicaltrials.gov (NCT02761382). Data was collected from March 2016 to October 2018.Participants were recruited from three specialized outpatient clinics for endometriosis in Denmark and from the Danish Endometriosis Patients Association. All patients considered for inclusion underwent screening to assess in- and exclusion criteria. Inclusion criteria were: (a) 18–47 years old, (b) surgery or MRI-confirmed endometriosis diagnosis, (c) moderate to severe CPP  from 0 = no pain to 10 = worst pain imaginable), (d) relevant clinical and surgical treatment according to the European Society of Human Reproduction and Embryology (ESHRE) guidelines for endometriosis  had beenA letter was sent to interested patients with study details and a pain diary to be filled out before the screening session. At the screening, patients were informed about study requirements and screened for in- and exclusion criteria. They provided written informed consent before enrolment in the study and randomization. Patients were informed that they would be randomized to one of two different psychological interventions or a waitlist control group. This should keep participants blinded to the psychological method and intervention content in the comparison group. To keep the research group blinded to intervention assignment throughout data collection, a research assistant, not part of the research group, provided patients with an anonymous id-number used for data collection. The numbers were randomized in blocks of six by another research assistant using a computer-generated randomization list.Questionnaires were sent to participants by postal mail, filled out, and returned. Baseline measurements were obtained during the 2 weeks period prior to treatment start, and post-intervention measurements were obtained during the 2 weeks post-treatment period. At home, patients also completed a 12-week pain diary starting 1 week pre-intervention until 1-week post-intervention. To investigate potential changes in pain processing and sensibility a female doctor carried out a gynecological experimental pain assessment during the 2-week period prior to treatment start and again during the 2 weeks post-treatment. However, the experimental pain assessment was optional and not required for participation  , 34 in cTo properly test whether MY-ENDO was truly superior to other psychological interventions and if the effects were due to specific mindfulness ingredients, the control condition had to be an intervention based on psychological principles. This means: 1) to have a cogent and acceptable rationale (2) to include corresponding therapeutic actions, and (3) to be delivered by trained therapists in a healing context with expectations that the therapy would be beneficial –38. Ther to have The Wait-list group received medical treatment as usual and completed the same questionnaires and gynecological pain assessment as the intervention groups.Two private practicing clinical psychologists, both licensed by the Danish board of psychologists and closely matched on essential parameters , were recruited to deliver the interventions in a “crossed-therapist” design, with both therapists providing both treatments within the study.Along with a sociodemographic questionnaire, patients received the following questionnaires:Pelvic pain intensity and pelvic pain unpleasantness were measured on NRS in a daily pain diary [in diary .Endometriosis-related QoL was measured by a validated Danish version of The Endometriosis Health Profile 30 questionnaire (EHP-30) [(EHP-30) , 41.Workability was measured by The Work Ability Index (WAI) [ex (WAI) , 43. We Endometriosis-related symptoms [symptoms  were measymptoms .Acceptance of chronic pain was measured by a validated Danish version of The Chronic Pain Acceptance Questionnaire (CPAQ) [e (CPAQ) –46.Vaginal pressure pain detection threshold (PPDT) was examined with a modified pressure algometer  applicable for intravaginal pelvic floor muscle examination . Due to large variability when measuring at other vaginal sites, the tissue around the sciatic spine was chosen for examination [mination . ParticiOther measures: At home, patients in the intervention groups filled out a daily home-work diary during the entire course of treatment.n1 = 6.0, Mean n2 = 5.0, SD = 1.5, power (1 − β) = 0.80, α = 0.05, two-sample, two-sided test, the number of participants needed would be 53 vs. 27 participants for differences between the groups PI vs. WL, and 36 vs. 36 participants for differences between the groups MY-ENDO vs. Non-specific. QoL was measured on EHP-30. The EHP-30 scale scores are standardized on a range from 0 to 100, defined by a mean of M = 50.0 and the standard deviation SD = 12.0. With the reasonable assumptions: Mean n1 = 50.0, Mean n2 = 40.0, SD = 12.0, power = 0.80, α = 0.05, two-sample, two-sided test, the number of participants needed would be 34 vs. 17 participants for differences between the groups PI vs. WL. Based on the power analyses it was planned to include 3 × 27 participants in the study.Sample size was based on power analysis of a small randomized 3-armed pilot study (unpublished) for the primary outcome of pelvic pain between the groups: (1) PI vs. WL and (2) MY-ENDO vs. Non-specific and for the secondary outcome of QoL between the groups PI vs. WL. Pelvic pain was measured on NRS. The NRS scale score is standardized on a range from 0–10, defined by a mean of M = 6.0 and the standard deviation (SD) = 1.5. With the reasonable assumptions: Mean χ2-test or the Kruskal–Wallis test . For continuous data, means and standard deviations were given. Normally distributed variables were compared using t-tests, and non-normally distributed variables were compared using non-parametric tests . Study dropouts were defined as participants discontinuing the intervention or failing to return the questionnaires/diary. Mixed linear models (MLMs) were used to compare groups over time and to examine changes in outcomes over time within groups on all outcomes. MLMs tolerate missing values without compromising statistical power and take into account the nested nature of data. The MLM models were conducted using restricted maximum likelihood method (REML) and performed on an intention-to-treat basis. Data were hierarchically arranged with time as level one nested within individual as level two. Fixed effects were specified for intercept, time, group, and time × group interaction. All models included a random intercept, and a fixed slope was chosen due to the comparison of groups with small sample sizes. In order to compare end-point effects between measures, a linear function of time was estimated from baseline to post-treatment measure. All primary analyses were conducted blinded. Since analyses of the primary outcome yielded unexplained results, which were in contrast to the hypotheses, statistically significant (P < 0.05) baseline differences were entered as covariates in explorative post-hoc analyses of the primary outcome [P < 0.05 (two-sided significance level). Effect sizes were expressed as Cohen´s d, with effect sizes of 0.2, 0.5, and 0.8 considered small, medium, and large, respectively. IBM SPSS statistics v.26 was used for all analyses.Baseline group differences were compared by the  outcome . In addiNMY-ENDO = 20, NNon-specific = 19, NWL = 19) were included in the study. The CONSORT study flow diagram is shown in Fig. P = 0.856). Nor were there any statistically significant differences regarding baseline characteristics for dropouts (N = 12) compared to completers (N = 42) except for previous use of alternative treatments (P = 0.020) as none of the dropouts had any previous experience with alternative treatments for endometriosis compared to 33.3% of completers.A total of 58 patients (P = 0.050), and the use of pain medication was therefore adjusted for in post-hoc analyses of the primary outcome [Sociodemographic, clinical, and pain-related data are shown in Table  outcome .Table 2SP = 0.009, d = 0.23) and unpleasantness   no longer reached statistical significance , ‘emotional wellbeing’  and ‘social support’ , and for the endometriosis-related symptoms ‘dyschezia’ , ‘constipation’  and ‘nausea’   and pelvic pain unpleasantness . The sensitivity analyses testing the robustness of the results yielded comparable results  nor pelvic pain unpleasantness  reached statistical significance  .With regards to the time spent on home practice, we did not find a significant difference between MY-ENDO  and Non-specific  in the average amount of time (min/day) spent on homework during the 10-week treatment period  are found in Table P = 0.001, d = 0.29) and pelvic pain unpleasantness . In the group taking pain medication, a significant reduction in pelvic pain intensity  and pelvic pain unpleasantness  was found, whereas in the group not taking pain medication, a significant increase in pelvic pain intensity  and pelvic pain unpleasantness  was found  independent of randomization allocation, statistically significant time × group effects were found for pelvic pain intensity  and nausea  and no statistically significant therapist x treatment interactions except for nausea .Statistical analysis revealed no significant therapist x time interactions except for work ability  does not significantly reduce pelvic pain in women suffering from endometriosis. Instead, PI led to large and significant improvements in QoL despite an ongoing experience of severe CPP.Cochrane meta-analyses of psychological interventions have found that in a range of chronic pain conditions, lasting on average 9 years, Cognitive and Behavioral Therapy (CBT) shows small benefits in pain compared to active control conditions. Behavioral Therapy and ACT did not show such effects , 23. TheThe present study also found significant improvements in the endometriosis-related symptoms “dyschezia” and “constipation”. Studies indicate that bowel symptoms are frequent in endometriosis with interruptions in daily functioning . These fin general may be helpful in improving symptom management and QoL in patients suffering from endometrioses. This could potentially make psychological interventions more accessible for patients in clinical practice. Yet, future studies with larger sample sizes are needed to determine whether there might be specific benefits of adopting a mindfulness- and acceptance-based approach over a non-specific psychological approach in the management of endometriosis.Contrary to the majority of previous studies comparing mindfulness- and acceptance-based intervention to an active control –54, we dNotably, this study has some strengths that are rarely seen in RCTs examining the effects of psychological interventions. The inclusion of a carefully matched non-specific control condition and a no-treatment control in a 3-armed RCT together with the attempt to reduce significant threats to internal validity  entails that the findings of this study may be highly robust.pelvic pain intensity and pelvic pain unpleasantness. However, these differences appeared to be driven by significant improvements in the waitlist group and may be explained by differences in the use of pain medication. This explanation was further substantiated by the results of the post-hoc analysis and the results of the experimental pain test and it cannot be ruled out that the use of pain medication might have influenced the pain results.According to the power analysis we needed 81 participants to be able to detect significant differences in the primary outcome. Despite a smaller sample size, significant differences were found between the groups for the primary outcome While the small sample size would contribute considerably to the risk of type 2 error, one should also bear in mind that a large number of statistical tests were performed in the study, and hence there is considerable risk of type 1 error. Still, some interesting significant pre-post changes were found in our data including increased workability and lower fatigue in the MY-ENDO group. However, these effects did not show statistically significant differences between the groups, and larger sample sizes are needed in future studies to answer questions about specificity.Recruiting participants was difficult due to patients suffering from physical disabilities and lack of energy making the 3-h in-person commitment a barrier to participation. Other barriers were geographical distance and working schedules.Future studies could try new ways to overcome these limitations for example by stratifying participants by use of pain medication and offering digitally delivered therapy to this patient group.Standard treatment for endometriosis is primarily focused on hormonal treatment, pain medication, and surgery. However, medical treatment can induce serious side effects leading to discontinuation of treatment and recurrence of symptoms, and surgery that resolves endometriosis may not necessarily resolve pain since the extent of pain may be unrelated to the extent of disease .With this rigorous three-armed RCT we have demonstrated that PIs specifically targeting endometriosis can lead to significant and large improvements in QoL and improvements in dyschezia and constipation despite an ongoing experience of severe CPP. Therefore, PIs aimed at symptom management and the improvement of QoL could be an appropriate supplement to an interdisciplinary endometriosis treatment.


In the LD task, the patients with CPP made more mistakes than the healthy individuals. IMI could be a useful and complementary tool in the therapeutic approach for patients with CPP.Implicit motor imagery (IMI), with an image laterality discrimination (LD) task, has been proposed as a useful therapeutic tool to restore body schema in patients with chronic pelvic pain (CPP). The aim of this study was to analyse the existence of differences between patients with CPP and healthy individuals in order to justify the use of IMI. An observational, cross-sectional study with non-probabilistic sampling was designed as a one-to-one matched case–control study. Through a web link designed for this purpose, a total of 40 abdominoperineal images were shown to 130 participants during the laterality task. Outcome measures were pain intensity , accuracy, response time (RT), and CPPQ-Mohedo score (Chronic Pelvic Pain Questionnaire—Mohedo). This was an observational, cross-sectional study with a total of 64 CPP patients and 66 healthy individuals. The comparative analysis between groups revealed significant differences in accuracy, CPPQ-Mohedo and VAS ( Chronic pelvic pain (CPP) is defined as “the chronic or persistent pain that is perceived in the structures related to the pelvis in men and women”. It often coexists with symptoms that suggest a lower urinary tract, sexual, intestinal, pelvic floor, or gynaecological dysfunction. When associated with negative cognitive, behavioural, sexual, and emotional consequences, it is known as CPP syndrome .CPP has been described as a global public mental health priority and it is among the most prevalent healthcare problems (14.8% in older women over 25 years of age) ,4,5. MorAccording to the International Classification of Diseases , althougSuch cortical reorganisation is characterised by an increase in the excitatory neural activity, along with a decrease in the inhibitory neural activity, in addition to alterations in the amount of grey matter in the anterior insula, amygdala , primaryIn view of such a complex clinical reality, to date, the first line of treatment for CPP is pharmacological therapy, with surgical intervention being the last choice, with little success. Currently, there is increasing support in the literature that shows that chronic pain is associated with the interruption of the cortically supported body schema ,27,28,29GMI is defined as a non-pharmacological and non-invasive treatment constituted by three phases conducted gradually and in an orderly manner and aimed at treating certain painful conditions. It was created and developed by David S. Butler and G. Lorimer Moseley during the first decade of the 21st century, when a better understanding of the interactions between the brain, the peripheral tissues, and the environment of the patient required new therapeutic approaches that addressed the brain areas involved in the painful movement ,31.Initially, GMI uses implicit motor imagery (IMI), with a laterality discrimination (LD) task. This first stage assesses the capacity of the individual to evaluate whether the body image observed belongs to the right or left side. During this task, both the accuracy (number of correct answers) and the RT (response time: time spent to provide the correct answer) are analysed, since these parameters are potentially altered in many painful conditions, both acute and chronic.In healthy people, response times are proportional to the time taken to physically move their physical body part to match the image  and are Jackson et al. demonstrated that internal mental images produce major sensorimotor cortical activity . Along tA recent systematic review revealed that poor motor imagery performance on the LD was a common feature of chronic peripheral musculoskeletal pain conditions , and thaThese findings suggest that determining IMI performance in people with chronic pelvic pain is warranted. If IMI is found altered in people with chronic pelvic pain, this may indicate disruption of the working body schema, improving the understanding of the condition, and it may provide the opportunity for novel treatment methods such as graded motor imagery.The current therapeutic approach for CPP is based on the biopsychosocial model, and it proposes multimode interventions, which are insufficiently implemented in the public healthcare system.Inspired by these findings and motivated by the innovation of mobile health in chronic diseases, we proposed to improve the available therapies for CPP, creating and developing a mobile application.We are currently immersed in the development of an app for these patients, in which, in addition to offering resources of therapeutic education regarding pain and advice on therapeutic exercise , we explored the usefulness of including IMI techniques as an added functionality. Thus, it was necessary to carry out this study, whose results help us to estimate its possible utility as a complementary therapeutic tool.Since this app is currently being developed, the present study only includes the LD task, through a web link that was designed for this purpose.We hypothesised that CPP would be associated with delayed responses and/or reduced accuracy of the abdominoperineal LD task. Our secondary hypothesis was that pain intensity in patients with CPP would be negatively related to parameters on the abdominoperineal LD task (accuracy and RT), age, and CPPQ-Mohedo score.to explore the existence of significant differences between groups measured in percentage of accuracy and RT;to determine the existence of correlation between pain intensity in patients diagnosed with CPP and: (a) age, (b) the CPPQ-Mohedo questionnaire score, (c) the number of correct answers in the LD task of such images, and (d) RT in such discrimination.The aim of the study was, using a pelvic floor LD, in people with and without CPP:An observational, cross-sectional study with non-probabilistic sampling was conducted to assess the ability to identify and discriminate pelvic floor images among chronic pain patients with non-chronic pain patients as the control group (CG). The study was designed as a one-to-one matched case–control study. Each participant was paired with at least one participant of the same sex and age (±5 years). The design followed the international recommendations for Strengthening the Reporting of Observational Studies in Epidemiology . The datA non-probabilistic sampling by convenience was performed, obtaining a sample of 26 patients from ADOPEC (Chronic Pelvic Pain Association in Spain), 38 patients referred by health professionals, and 66 volunteers for the control group recruited through the patients and/or professionals themselves, as well as through social networks (CG).The inclusion criteria for the CPP patients were as follows: (a) having a clinical diagnosis of CPP , (b) SpaA visual analogue scale (VAS)  was usedThe number of correct responses was expressed as a percentage over the total number of pictures displayed .This is the length of time taken to answer whether a picture is right or left. The mean RT spent to complete the test was expressed in minutes and seconds .A questionnaire to help discriminate between patients with and without CPP symptoms  was used, with a cutoff point of 6 .All variables were collected through an electronic link.Control task: left/right judgements of photographs of the abdominoperineal area.®, SAVE CREATIVE (20/04/2020). COD: 2004213727578). The term sex is used as a classification of male or female based on biological distinction of genitalia throughout the manuscript. A total of 40 images were shown to each participant [The participants undertook the left/right abdominoperineal area judgement task using the established protocol. Five hundred and fifty photographs of the right and left side, in different positions and divided by sexes, were employed in random order, with the participants accessing these photographs through a web link to part of the software of an app in the process of development and implementation  and R Core Team (2022) ,43.t tests were used to analyse differences between sexes, and Pearson’s linear correlation to explore the linear association between the percentage of correct answers and RT in the images. The Chi-squared test was used to explore the association between the qualitative variables. The level of significance was defined at p < 0.05.Background variables are presented as means with a standard deviation and ranges or frequencies and percentages. Student’s The total study sample consisted of 147 participants, of whom 17 patients were excluded for being diagnosed with dyslexia. Finally, 130 participants met the inclusion criteria and were evenly divided into two groups (64 CPP patients and 66 CG).p > 0.05).There were no statistically significant differences in the sociodemographic data between the two groups, as is shown in p < 0.001), but not in RT; these results are shown in The comparative analysis between groups revealed significant differences in accuracy, CPPQ-Mohedo, and VAS variables  in CPPQ-Mohedo questionnaire score, VAS, and accuracy; that is, the case group obtained greater scores in pain intensity and lower accuracy in the LD task compared to the control group. There were no differences with respect to the time spent to complete the image discrimination task.Furthermore, there was a significant correlation between several variables. On the one hand, the greater the age, the longer the time spent to complete the task and the greater the pain intensity; similarly, the larger the number of correct answers, the shorter the time spent to complete the task (better performance). Lastly, a greater pain intensity was significantly correlated with a greater score in the discriminant questionnaire, lower accuracy, and longer RT in the LD task.The results were in line with those obtained in similar studies, although the latter were conducted on other lethal chronic conditions, such as complex regional pain syndrome , phantomTaking the mentioned studies as reference, one of the aspects that were considered for the present study was the question of whether GMI would be applicable in this case, given the absence of the concept of spatial laterality in the pelvic floor , as well as its representation in the cortex compared to the other locations.Currently, the cortical somatosensory representation of the genitals in women and men is still poorly understood, and contradicting results have been reported.Since the study of Penfield and Rasmussen in 1950 , which wRegarding pelvic floor musculature control, the key areas of the brain involved are the primary motor cortex, the supplementary motor area, the cingulate gyrus, the putamen, the thalamus, the prefrontal cortex, the supramarginal gyrus, the insula, and the cerebellum ,52.The mentioned studies have verified the representation and activation of such cortical areas through the visualisation of erotic images or application of tactile stimulation in the genital area or through the request for voluntary muscle contraction and control of urination in healthy individuals, respectively ,53.In CPP, a motor cortical alteration of the pelvic floor has been described, showing that this is an important study area, which could also predict how the patient would respond to the treatment. For instance, in recent neuroimaging studies at rest, with respect to healthy controls, the patients with chronic pelvic pain exhibited an altered frequency content of the obtained functional magnetic resonance imaging (fMRI) of a specific motor region of the pelvis and an altered connectivity between said motor region and other regions of the brain . FurtherIn the present study, although this interruption of the body schema, specifically of the pelvic floor, has not been evidenced to date, owing to the lack of imagery techniques that refute our results, the cortical alteration appeared slightly in the smaller number of correct answers (or more mistakes) obtained during the task performed in our case group, with respect to the CG. It is important to highlight that bad sexual experiences or sexual abuse are strongly associated with CPP , and thuIn addition to the sensitive part that comprises the genital area, it is known that there is poor proprioception of the pelvic muscles, which can be attributed to the lack of visual stimuli and the scarce joint movement during contraction. This proprioceptive deficit is combined with women’s lack of knowledge about their pelvic and genital area .It is clear that the LD task of GMI with the images presented to the sample of this study required the activation of “possibly affected” brain areas, although this cannot confirm the influence of a proprioceptive deficit, poor self-image, or bad sexual experiences. It can only assert that these participants found it more difficult to plan, adjust, automatise, and voluntarily execute the postures and/or movements shown in the images. It would be interesting for future studies to gather these variables and estimate their relationship with the results obtained in the present study.Regarding the lack of significance with respect to RT, the results were in line with those of other authors ,47, who These results of RT in our study could be partly explained by the lack of knowledge, poor identification, and self-perception of the pelvic and genital area in the general population , and thus the poor motor control of the pelvic floor musculature. For example, in a previous study , 98% of In this study, this variable showed a statistically significant difference between groups, which was in line with the findings of other authors, who, in addition to reporting such differences between groups  , demonstRegarding age, the results were in line with those reported in chronic shoulder pain by Breckenridge JD et al.  and RavaNatural ageing involves a physiological defect in the somatosensory system, from the receptors, with a decrease in all sensory sources, to the processing at the CNS.When brain activity is analysed through functional magnetic resonance, it can be observed that, with age, there is a decrease in functional connectivity between different brain regions, including the posterior cingulate cortex, the praecuneus, the medial prefrontal cortex, and the lateral parietal cortex, which systematically show a decrease in activation compared to the baseline during the execution of the task .Landelle et al.  analysedCPPQ-Mohedo  has provRegarding pain, a positive correlation between pain intensity and RT was found, as well as a negative correlation between pain intensity and accuracy in the test (number of correct answers); thus, the greater the pain intensity of the lumbar-pelvic-perineal area, the smaller the number of correct answers and the longer the RT; this was in line with the results of other authors in their studies on low back pain ,48,71, wPain intensity is a very complex variable in constant controversy, as it can vary in patients with CPP and influence their performance in the task depending on many more variables ,64, suchHowever, several authors ,78 stateThese results related to pain intensity raise questions on whether pain intensity could be an essential factor to be taken into account when determining the suitability of IMI as a complementary therapeutic tool in the approach for CPP.To date, no guide or protocol has been published to specify the correct procedure to evaluate the results of the IMI task . Only one study  was founThe use of IMI with the LD task has proved to be a reliable, non-invasive method with no adverse effects, which makes it a suitable evaluation and complementary technique in the approach for any chronic pain , includiApp-Mohedo is a tool under development and implementation that has been developed for mobile devices, and which, in addition to accessing therapeutic resources , will allow evaluating and training-improving the capacity of the individual to assess whether the observed image of the pelviperineal area belongs to the left or right side of the body. During this task, both the accuracy (number of correct answers) and RT (response time) are analysed, which are parameters that showed potential alteration in painful conditions such as CPP. The aim is to inform, with further studies, whether such training influences the modulation and decrease in pain intensity and the functional improvement of these patients, which is the end goal of this project.During sample collection, comorbidity with other pathologies for which the patients were receiving another treatment at the moment of the study was not taken into account. In the case of women, they were matched up based on whether they had given birth, although disregarding the number of births.On the other hand, the researcher was aware at all times of the group that each participant belonged to.Because of its characteristics, the use of IMI depends on each particular individual’s capacity for imagination, as well as on the level of the self-image of the genital area. The present study did not use any tool that evaluated this aspect.Since the study was conducted online, it was not possible to quantify the pelvic floor musculature motor control in the participants and, therefore, it was not possible to correlate the results with a possible motor control deficit.The small number of patients included in the final sample, after applying our criteria, was a limitation. The results were conclusive, although; with a larger sample size, more statistically significant results could be achieved.There are significant differences in the number of correct answers between CPP patients and the CG: the patients made more mistakes than the healthy individuals.The greater the pain intensity of the patients diagnosed with CPP, the greater the score in the CPPQ-Mohedo questionnaire, the smaller the number of correct answers, and the longer the time required to complete the LD task with pelvic floor images. The greater the age of the patients, the longer the RT and the greater the score in the CPPQ-Mohedo.In the IMI laterality discrimination task performed in the sample:IMI can be a useful and complementary tool to help, with pelvic floor images, to activate and reorganise the cerebral cortex and its inhibitory mechanisms in patients with CPP. It will be necessary to reproduce the study in a larger sample to obtain more powerful statistical results.


Single-port access (SPA) laparoscopy requires only one incision, unlike conventional laparoscopy. However, its umbilical incision is larger than that of conventional laparoscopy and can be vulnerable to postoperative pain. This study aimed to evaluate whether simultaneous use of a continuous wound infiltration (CWI) system and intravenous patient-controlled analgesia (IV PCA) effectively decreases surgical site pain in patients who underwent SPA laparoscopy due to gynecologic adnexal disease.n = 159] vs. PCA group ). To evaluate postoperative pain management, the numeric rating scale (NRS) pain score after surgery, total amount of fentanyl administered via IV PCA, and additional pain killer consumption were collected.A total of 371 patients who underwent SPA laparoscopy and who received IV PCA or CWI was retrospectively reviewed  and 24 h  after surgery were significantly lower in the combined group than in the PCA group. The total amount of PCA fentanyl was significantly smaller in the combined group than in the PCA group (p < 0.001). The total quantity of rescue analgesics was smaller in the combined group than in the PCA group (p < 0.05).The NRS scores at 12 h (1.90 ± 1.11 vs. 2.70 ± 1.08, Combined use of the CWI system and IV PCA is an effective postoperative pain management strategy in patient who underwent SPA laparoscopy for adnexal disease. SPA Postoperative pain is one of the major concerns for patients before undergoing surgery . InadequTherefore, the purpose of this study was to evaluate whether simultaneous use of the CWI system and IV PCA effectively decreases postoperative surgical site pain compared with IV PCA alone in patients who underwent SPA laparoscopy due to gynecologic adnexal diseases.2.2.1.We retrospectively reviewed patients who underwent SPA laparoscopy for adnexal disease in Kangbuk Samsung Hospital and or Uijeongbu Eulji Medical Center between January 1, 2020 and August 31, 2022. This study was approved by the Institutional Review Boards (IRBs) of Kangbuk Samsung Hospital (IRB no. 2022–12-030) and Eulji University (IRB no. 2023–02-015). Patients who met the following criteria were eligible for this study: (1) those who underwent adnexal surgery including ovarian cystectomy or salpingo-oophorectomy, (2) those who underwent IV PCA or CWI for postoperative pain control, and (3) those whose pain score at 6, 12, 24, and 48 h after surgery were adequately assessed using the numeric rating scale (NRS). We excluded patients who met one or more of the following criteria: (1) those who underwent another gynecologic surgery (such as hysterectomy or myomectomy) simultaneously, (2) those who were converted to multiport laparoscopy or laparotomy during surgery, and (3) those in which the IV PCA or CWI system was not sufficiently maintained during hospitalization because of side effects. Patients were then classified into the combined group (IV PCA and CWI system) and the PCA group (IV PCA only).2.1.1.Patient baseline characteristics including age, body mass index (BMI), and history of abdominal surgery were collected. Total operative time, perioperative complications, estimated blood loss (EBL), serum hemoglobin (Hb) level difference, single-port placement time, specimen retrieval time, length of umbilical incision before and after surgery, duration of hospital stay, and pathologic diagnosis were recorded for surgical outcomes. The total operative time was defined as the time from skin incision to skin closure. EBL was calculated by the anesthesiology unit as the difference between the total amounts of suction and irrigation. Serum Hb level difference was defined as the change between preoperative Hb level and Hb level on postoperative day 1. The single-port placement time was defined as the time for which pneumoperitoneum was maintained by insufflating carbon dioxide (CO2) gas. We defined specimen retrieval time as the total time required to remove the resected tissue through the in-bag removal process. To evaluate umbilical incision enlargement due to the elastic wound retractor of the single-port system and specimen retrieval process during surgery, the longest vertical length of umbilical incision was measured before and after surgery with the wound retractor inserted . The lenFor postoperative pain outcomes, the NRS, ranging from 0 (no pain) to 10 (worst pain), was used to assess surgical site pain at 6, 12, 24, and 48 h after surgery. The total amount of fentanyl citrate administered via IV PCA during the entire hospitalization period was recorded. The timing and amount of additional pain killers such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioid drugs were also recorded. In both institutions, the routine pain management protocol after SPA laparoscopy for adnexal disease is as follows. All patients underwent IV PCA routinely at the post-anesthesia care unit as a baseline pain management method immediately after surgery. The CWI system was performed in some patients, though there were no definite clinical criteria for its use. However, before surgery, detailed counseling for the clinical benefits, risks, and cost of the CWI system was offered to patients. The patients made their own decision whether receive the CWI system in addition to baseline IV PCA, and the system was applied only to patients who consented to the procedure. For IV PCA, 900–1800 μg fentanyl citrate was mixed with 100 mL of 0.9% normal saline , the guiding needle was inserted into the subcutaneous layer from the lower end of the vertical umbilical incision to a point 7–10 cm below it . Normality of the data was assessed with the Shapiro–Wilk test. Data with normal distribution are presented as mean ± standard deviation (SD), while median  were used for data with non-normal distribution. Frequency distributions among categorical variables for the two pain control methods were compared using the chi-square test or Fisher’s exact test. Multiple linear regression analysis models were used to estimate the independent contributions of variables to postoperative pain. A value of 3.During the study period, 431 patients underwent SPA laparoscopy for adnexal disease and received IV PCA or CWI for postoperative pain management. Of these, 60 patients who could not maintain IV PCA until discharge due to side effects were excluded. A total of 371 patients was enrolled in this study, comprising 212 (57.1%) patients who received only IV PCA (PCA group) and 159 (42.9%) patients who received IV PCA and CWI concurrently (combined group) . The patp < 0.001) and 24 h  after surgery were significantly lower in the combined group compared with PCA group. For the remaining period, the pain intensity of the combined group tended to be lower than that of the PCA group, but it did not show statistical significance. The total amount of fentanyl citrate administered via IV PCA during the entire hospitalization period was significantly less in the combined group than in the PCA group . The percentage of patients requiring rescue analgesics after surgery was lower in the combined group than in the PCA group, and in particular, there was a significant difference between 6 and 12 h after surgery . In addition, the CWI system significantly reduced the total amount of rescue analgesics administered from 6 to 12 h after surgery . The use of higher potency rescue analgesics was less frequent in the combined group than the PCA group, but the difference was not significant.The pain control outcomes according to pain management method are presented in β = 2.752, p = 0.001), longer total operative time , and longer single-port placement time  were related to pain score at postoperative 6 h. However, there was no correlation between these factors and postoperative 12, 24, and 48 h pain scores. Simultaneous use of CWI and IV PCA was an independent postoperative pain-reducing factor during the entire hospitalization period in multivariate analysis.In univariate and multivariate linear regression analyzes of postoperative pain score , postopep = 0.027). Wound discharge of the umbilical incision site occurred only in the combined group maintaining CWI . After removal of CWI, wound complications such as infection and hernia were not different between the two groups.The incidence of side effects in both patient groups is shown in 4.This study evaluated the efficacy of the CWI system for postoperative pain management after SPA laparoscopy in patients with gynecologic adnexal disease. We found that simultaneous use of the CWI system and IV PCA (combined group) significantly reduced the immediate postoperative pain scores and the total amount of IV PCA fentanyl during the entire hospitalization. We also found that the CWI system reduces the use of additional analgesics and the incidence of adverse events such as nausea and vomiting.Paints with gynecologic adnexal diseases may suffer from disease-specific pain before surgery and surgery-related pain after surgery. For instance, endometriosis is a representative disease that cause sever pelvic pain by creating inflammatory change, activating immune response, and increasing innervation in the affected tissue . In addiThe ERAS protocols to reduce hospitalization period and morbidity have become the standard for postoperative patient care after gynecologic surgery. Adequate postoperative pain management through combined use of analgesics with a different mechanism of action is a key component of the ERAS pathway. Furthermore, since the pain response to the same surgery and routine postoperative pain management for each patient, it is also important to use an appropriate rescue analgesics tailored to each patient’s characteristics . RecentlThe CWI system effectively controls pain by directly injecting a local anesthetic agent into the surgical site. The ERAS group also recommended that incisional infiltration has no systemic side effects when used appropriately, and it should be incorporated into other pain control methods as a component of multimodal analgesia . Many prOur study demonstrated that combined use of the CWI system and IV PCA may be a safe and effective strategy to manage immediate postoperative pain in patients who underwent SPA laparoscopic adnexal surgery. Large-scale randomized trials are needed to evaluate the effectiveness of CWI in SPA laparoscopy.To the best of our knowledge, this is the first study to evaluate the efficacy of the CWI system for gynecologic SPA laparoscopy. Another strength of this study is that it was conducted with a relatively large number of patients. However, this study has some limitations. First, this was not a prospective, randomized clinical trial. Second, among various types of pain that may occur after laparoscopic surgery such as gas-induced abdominal pain, shoulder pain, and visceral pain , 17, onlThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.J-HK: conceptualization, software, visualization, and writing-original draft. J-HK and KL: data curation, investigation, and project administration. J-HK and EP: formal analysis. J-HK and WK: methodology. EP and YH: validation. KL and YH: resources. EP and WK: supervision. EP, KL, and WK: writing-review and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The high CCI group had a higher incidence of cancer than the low CCI group . The en bloc resection rate  and complete resection rate  were not significantly different between the two groups. Colorectal ESD can be safely and effectively performed in patients with various underlying medical conditions.Endoscopic submucosal dissection (ESD) is an effective method for removing early colorectal lesions. However, research on the safety and efficacy of ESD in patients with various underlying conditions remains limited. This study retrospectively examined ESD outcomes in colorectal neoplasm patients from five tertiary medical centers. The Charlson Comorbidity Index (CCI) and age-adjusted CCI (ACCI) were analyzed, and the differences in complete resection and complication rates were analyzed. The CCI, ACCI, and complication rates tended to gradually increase proportionally, and the complication resection rate increased from CCI 2 to ACCI 4 as the starting point, followed by a decreasing trend. Of these, 140 patients (9.7%) had a CCI score of 3 or higher. The high CCI group was older (70.6% vs. 64.7%,  The detection rate of colorectal cancer is increasing with the development of colonoscopy, early screening, and the discovery of early lesions in colon neoplasms ,2. EndosAccording to the Korean Clinical Practice Guidelines for Endoscopic Resection of Early Gastrointestinal Cancer, ESD is preferred over EMR for early colorectal cancer . The EurIn real-world clinical settings, endoscopists must consider comorbidities, performance status, and expected survival ,8. ReseaThe age-adjusted CCI (ACCI) is a value that increases by 1 every 10 years when the patient is 50 years or older and is calculated by adding it to the original CCI. This number is also determined by calculating the factor of age together with the underlying disease . Recent This multicenter, retrospective study used data collected between January 2015 and December 2020. Data were collected from five tertiary medical centers  in the Honam Province, South Korea. A total of 1446 patients who underwent endoscopic submucosal resection of colorectal epithelial tumors were analyzed. We reviewed the medical records and extracted information on the demographic and clinical characteristics, procedural outcomes, and procedure- or sedation-related complications of colorectal ESD.This retrospective multicenter study obtained the necessary ethical approval from the respective institutional review boards and ethics committees in accordance with the principles outlined in the Declaration of Helsinki. The study protocol and data collection procedures were reviewed and deemed ethically acceptable, taking into consideration the rights, welfare, and privacy of the study participants. All patient information used in this study was de-identified and handled with strict confidentiality. The study was conducted in compliance with the applicable regulations, guidelines, and ethical standards to ensure the integrity and validity of the research findings.Data on age, sex, location, gross morphology, lesion size, procedure time, pathological findings, presence of fibrosis, adverse events, and complete resection rates were collected. The lesion location was categorized into three groups: right colon , left colon (descending colon and sigmoid colon), and rectum. The macroscopic appearance of lesions was classified as protruded, flat-elevated, or flattened/depressed according to the Paris classification . En-bloc®) was administered when a paradoxical reaction or desaturation was observed during sedative endoscopy. Procedure-associated bleeding was defined as bleeding necessitating transfusion, urgent endoscopy, or a decrease in hemoglobin levels by more than 2 g/dL after the procedure [Patients were sedated with midazolam, propofol, or both. Supplementary oxygen was administered to maintain arterial oxygen saturation > 90%. Blood pressure, heart rate, and oxygen saturation levels were monitored during the procedure. Hypotension during the procedure was characterized by a systolic blood pressure below 90 mmHg. Oxygen desaturation was defined as an arterial oxygen saturation of less than 90%, persisting for a minimum of 10 s. An antidote for midazolam .Continuous data were presented as mean ± standard deviation or median (range), while categorical data were displayed as absolute or relative frequencies. The Student’s Experiments were conducted using restricted cubic splines with three knots. A restricted cubic spline curve was used to show the predicted probability (solid line) and 95% confidence intervals (shades) to evaluate the association of CCI and ACCI with complete resection and complication rates. Statistical analyses were conducted using Stata/SE 16.1 software .n = 691, 47.8%; 1 point, n = 383, 26.5%; 2 points, n = 233, 16.1%; 3 points, n = 65, 4.5%; 4 points, n = 35, 2.4%; and ≥5 points, n = 39, 2.7% , followed by solid tumors without recurrence (9.7%). 39, 2.7% . Similar69, 4.8% .A total of 1446 patients with colorectal neoplasm  were included in the final analysis. The mean longitudinal tumor size was 29.6 ± 12.3 mm). Colorectal neoplasms were located in the cecum and were ascending in 486 (33.6%) patients, transverse and descending in 322 (22.3%) patients, and sigmoid and rectal in 638 (44.1%) patients. The mean procedure time was 47.4 ± 46.4 min. Histological examination revealed 774 adenomas (53.5%), 300 intramucosal cancers (20.7%), and 372 invasive cancers (25.7%). The intake rates of aspirin, clopidogrel, and antithrombotic medications were 8.8%, 3.5%, and 1.0%, respectively. Sedative endoscopy was performed in 70.4% of the patients. Midazolam was administered to only 942 patients (65.1%), followed by midazolam and propofol  and propofol monotherapy .p < 0.01). Males were more dominant in the high CCI group (70.7%) than in the low CCI group . Advanced histologic lesions  were more frequent in the high CCI group (77.9%) than in the low CCI group . Aspirin  and clopidogrel  were more frequently described in the high CCI group than in the low CCI group. Sedative endoscopy was performed less frequently in the high CCI group (57.9%) than in the low CCI group .p = 0.79). Complete resection was performed in 75.7% and 81.2% of patients in the high and low CCI groups, respectively (p = 0.12).We plotted a restricted cubic spline curve representing the predicted probability (solid line) and 95% confidence intervals (shades). p = 0.88) did not differ significantly between the high and low CCI groups. Bleeding occurred in 2.4% of patients. The incidence of bleeding  did not differ significantly between the high and low CCI groups. PECS occurred in 2.8% of participants. PECS was similar in both groups . Hypotension  and desaturation (0% vs. 0%) during sedative endoscopy have rarely been reported.Perforation occurred in 0.6% of participants. The perforation rate . On average, patients underwent follow-up endoscopy 2.1 times, with a median of two times and a range spanning from one to 11 times. Among these, recurrence of colorectal neoplasms was observed in 20 patients (2.0%). Among patients confirmed with recurrence, surgery was performed in 12 (60%), additional ESD in 5, and the remaining 3 were followed up without further surgical intervention. Among the 978 patients who underwent follow-up endoscopy, 94 exhibited a CCI score of 3 or higher, while 884 had a CCI score below 3. In the high CCI group, encompassing 94 patients, the average duration of endoscopic follow-up amounted to 27.8 months, with a median duration of 23 months and a range spanning from 1–79 months. The number of follow-up endoscopies varied between one and seven, averaging 2.5 times and having a median of two times. Among the 94 patients in the high CCI group, colorectal neoplasm recurrence was verified in three (3.2%) patients. Within the low CCI group encompassing a total of 884 patients, the mean duration of endoscopy follow-up was 23.6 months, with a median duration of 14 months and a range spanning from 2–94 months. The frequency of follow-up endoscopies ranged from 1–11, with a median of 1 endoscopy and an average of 2. Colorectal neoplasm recurrence was detected in 17 of the 884 patients, constituting a rate of 1.9%. Assessing recurrence through Kaplan–Meier analysis with a log-rank test between the two groups revealed a p < 0.01).Among the 1446 patients, outpatient follow-up was conducted in 1412 patients. The average follow-up period was 21.4 months . During the follow-up period, five patients experienced mortality, accounting for 0.4% of the cohort. The causes of death included lung cancer, worsening of idiopathic pulmonary fibrosis, heart failure, aplastic anemia, and acute cholangitis, each occurring in one case. Importantly, no deaths attributed to colorectal neoplasms were recorded. In the high CCI group, comprising 135 patients, four died during the follow-up period, accounting for a mortality rate of 3.0%. The causes of death included lung cancer, heart failure, aplastic anemia, and acute cholangitis. In the low CCI group, which comprised 1277 patients, one died during the follow-up period. The cause of death was the exacerbation of idiopathic pulmonary fibrosis. Kaplan–Meier analysis with a log-rank test was performed to compare mortality rates between the high and low CCI groups, and the high CCI group demonstrated a significantly higher mortality rate . The complication occurrence model helps predict the occurrence of perforation, bleeding, or PECS, which shows a gentle upward trend in both the CCI and ACCI as the score increases. Nonetheless, upon dividing the CCI groups into high (≥3) and low (<3), the examination of complication rates failed to reveal any statistically significant differences between the two groups for each complication .An actual CCI score of 1 indicates a state with few underlying diseases. Therefore, it can be inferred that significant changes in the outcomes of colorectal ESD may not manifest until a low CCI score of 1 is achieved. The average age of 65 years in this study implies that the ACCI would likely be 1–2 points higher than the CCI. Consequently, this suggests that an ACCI score of 3–4 might not be sufficiently elevated to significantly impact the complete resection rate compared to an ACCI of 0–2. When the complete resection rate was investigated by dividing the CCI group into high (≥3) and low (<3) groups, no significant difference was observed between the two groups for each complication . In patients with many underlying diseases, sedative endoscopy was performed in a relatively small number of patients owing to concerns about complications related to sedative endoscopy. In this study, complications related to sedative endoscopy were extremely low in both (high and low CCI groups). The comprehensive complication analysis did not include sedation-related complications such as desaturation because many patients did not undergo sedative endoscopy. Therefore, we did not include the contents of the overall complications section.The high CCI group underwent sedative endoscopy less frequently than the low CCI group . When analyzed by dividing the high CCI group from the low CCI group, we found no difference in the complication rate higher than expected or in the complete resection rate.p = 0.63). Among patients who experienced a recurrence, various treatment approaches were employed. However, the two groups had a notable disparity in all-cause mortality. Kaplan–Meier analysis revealed that the high CCI group exhibited a significantly higher mortality rate with statistical significance . Similar to this study, in cases where ESD of the esophagus and stomach was performed, high CCI was associated with decreased overall survival in long-term follow-up [The long-term outcome analysis indicated that the recurrence rate was not linked to a high CCI as per the Kaplan–Meier analysis (3.2% vs. 1.9%, ollow-up ,26.Initially, both the CCI and ACCI were devised as indices linked to the longitudinal survival rate based on the underlying disease scores ,14. HoweThis study has a few limitations. This was a retrospective study. Retrospective studies often rely on existing data, which may introduce selection bias owing to the non-randomized nature of data collection. As the results of ESD conducted in five institutions in one country were shown, there was a limit to representing the situation by country or institution. Nevertheless, it has the advantage of showing the relationship between the underlying disease and ESD through a large number of multicenter studies.The complete resection rate gradually decreased as the CCI and ACCI increased, and the incidence of complications gradually increased. When divided into the high CCI group and low CCI group, results showed that patients with a higher CCI score were older, had a higher incidence of cancer, and had higher intake rates of aspirin and clopidogrel. However, this study found no significant differences in the safety and efficacy of ESD between the high CCI group and low CCI groups. We conclude that colorectal ESD is a relatively safe and effective procedure despite various underlying diseases.