POSTOPERATIVE PAIN MANAGEMENT IN COMMANDO SURGERY AND FREE FIBULA FLAP RECONSTRUCTION: AN OBSERVATIONAL STUDY

A. Lombardo¹, E. Fontana², S. Iannarino¹, A. Mariotto¹, F. Stivala³, B. Cezza⁴, G. Riva¹, M. Miletta⁵, A. Toscano⁶, S. Valzan⁷, M. Paleologo⁵, G. Pecorari¹ | ¹S.C. Otorinolaringoiatria U, A.O.U. Città della Salute e della Scienza di Torino, Presidio Molinette, Italy; ²S.C. Otorinolaringoiatria, A.O.U. Città della Salute e della Scienza di Torino, Presidio Molinette, Italy; ³S.C. Pneumologia U, A.O.U. Città della Salute e della Scienza di Torino, Presidio Molinette, Italy; ⁴S.C. Anestesia e Rianimazione 2, A.O.U. Città della Salute e della Scienza di Torino, Presidio Molinette, Italy; ⁵S.C. Direzione Professioni Sanitarie (DiPSa), A.O.U. Città della Salute e della Scienza di Torino, Presidio Molinette, Italy; ⁶S.C. Anestesia e Rianimazione, ASL TO4, Ospedale di Ivrea, Italy; ⁷S.C. Anestesia e Rianimazione 1, A.O.U. Città della Salute e della Scienza di Torino, Presidio Molinette, Italy

Background. Patients with extensive tumors of the oral cavity and oropharynx, with mandibular infiltration, undergo a surgical procedure involving en bloc tumor resection, complete dissection of the regional lymph node stations, and full-thickness resection of an entire segment of the mandible. Reconstruction is performed through proximal and distal fibular osteotomy, dissection of the vascular pedicle and the flexor hallucis longus muscle, and their transfer to the recipient site in the oral cavity. This type of surgery, due to the extent of resection, the highly pain-sensitive anatomical site, the patient’s emotional burden, is associated with severe postoperative pain. If not adequately controlled, this exposes the patient to intense pain and a high risk of complications (1,2). To optimize pain management, a multidisciplinary team consisting of an anesthesiologist, a nurse, and a maxillofacial surgeon, developed a specific protocol. An observational study was conducted to evaluate its effectiveness.
Methods. From January 2025 to April 2026, 30 patients were observed, including 18 men and 12 women, aged between 45 and 80 years. On the day prior to surgery, patients were informed about postoperative pain management. The analgesic regimen used was as follows: Morphine 0.01–0.05 mg/kg/h via elastomeric pump Paracetamol 1 g three times daily Rescue dose in the intensive care unit: if pain > NRS 3, morphine 0.05–0.1 mg/kg IV Rescue dose in the ward: if pain > NRS 3, tramadol 50 mg in 100 ml normal saline over 15 minutes (infusion rate 400 ml/h), up to twice daily, or ketorolac 15–30 mg every 8 hours At the fibula donor site: interfascial catheter with ropivacaine 480 mg/24 h in 250 ml normal saline Parameters evaluated: Mean pain during the first 12 hours (T0–T12) Mean pain from 12 to 24 hours (T12–T24) Mean pain from 24 to 48 hours (T24–T48) Total rescue doses administered Nausea and vomiting
Results. T0–T12: mean pain NRS 0.60, with 90% of recordings at NRS 0 T12–T24: mean pain NRS 1.20, with 73.69% of recordings at NRS 0 T24–T48: mean pain NRS 0.96, with 84.33% of recordings at NRS 0 Total rescue doses administered: 6 Nausea: 6/30 (20%); Vomiting: 2/30 (6.67%)
Conclusions. Data analysis shows that pain was well controlled throughout the observation period, with values around NRS < 1 in the first 12 hours, then increasing to approximately NRS 1 between 12 and 24 hours, and subsequently decreasing between 24 and 48 hours to NRS < 1. Cumulative data indicate that the vast majority of measurements recorded over the 48-hour period were NRS 0 (82.6%). The total number of rescue doses administered was relatively low, supporting the effectiveness of the analgesic regimen. Outcomes related to nausea and vomiting were favorable. Overall, the analgesic protocol proved to be effective in terms of pain control and safe with regard to opioid-related side effects and pain-related complications. This resulted in significant positive impacts on patient care and quality of life.