Risk Of Chronic Postoperative Pain Research Articles

Kinins' Contribution to Postoperative Pain in an Experimental Animal Model and Its Implications.

Postoperative pain causes discomfort and disability, besides high medical costs. The search for better treatments for this pain is essential to improve recovery and reduce morbidity and risk of chronic postoperative pain. Kinins and their receptors contribute to different painful conditions and are among the main painful inflammatory mediators. We investigated the kinin's role in a postoperative pain model in mice and reviewed data associating kinins with this painful condition. The postoperative pain model was induced by an incision in the mice's paw's skin and fascia with the underlying muscle's elevation. Kinin levels were evaluated by enzyme immunoassays in sham or operated animals. Kinin's role in surgical procedure-associated mechanical allodynia was investigated using systemic or local administration of antagonists of the kinin B1 receptor (DALBk or SSR240612) or B2 receptor (Icatibant or FR173657) and a kallikrein inhibitor (aprotinin). Kinin levels increased in mice's serum and plantar tissue after the surgical procedure. All kinin B1 or B2 receptor antagonists and aprotinin reduced incision-induced mechanical allodynia. Although controversial, kinins contribute mainly to the initial phase of postoperative pain. The kallikrein-kinin system can be targeted to relieve this pain, but more investigations are necessary, especially associations with other pharmacologic targets.

Sex-Specific Associations Between Preoperative Chronic Pain and Moderate to Severe Chronic Postoperative Pain in Patients 2 Years After Cardiac Surgery.

Chronic postoperative pain (CPSP) after cardiac surgery can cause severe health problems. As demonstrated in noncardiac surgeries, preoperative chronic pain can potentially lead to CPSP. However, the association between preoperative chronic pain and CPSP over follow-up in cardiac surgical settings in the context of sex differences is still lacking. This observational study aims to explore the role and sex differences of preoperative chronic pain in the occurrence and development of long-term CPSP and CPSP-related complications after cardiac surgery. This observational study enrolled 495 patients (35.3% women) who underwent cardiac surgery via median sternotomy in March 2019. Validated questionnaires were delivered to assess preoperative chronic pain and moderate to severe CPSP at 3 and 24 months following surgical procedures. The secondary outcomes included the occurrence of moderate to severe chronic pruritus, sleep disturbance, and daily activities interference at follow-up. Multivariable logistic regression was employed. Of 495 patients analyzed, the incidences of preoperative chronic pain (29.7% versus 20.6%) and moderate to severe CPSP (14.8% versus 8.1%) were both higher in females than males. Female sex (P = 0.048) and preoperative chronic pain (P = 0.008) were identified as significant risk factors for CPSP occurrence. However, preoperative chronic pain contributed significantly to CPSP (P = 0.008), sleep disturbance (P =0.047), and daily activities interference (P =0.019) in females, but not in males. The 2-year prevalence of moderate to severe CPSP after cardiac surgery was 10.5%. Compared to males, females are more susceptible to CPSP and pain-related outcomes in the long term. In addition, preoperative chronic pain was associated with a higher risk of CPSP in females but not in males.

Results at 3-year follow-up of totally extraperitoneal (TEP) hernia surgery with long-term resorbable mesh

IntroductionSynthetic non-resorbable mesh is almost standard in hernia surgery. However, several studies have showed negative effects of permanent implants such as chronic inflammation and complications involving different organs bordering the mesh. Such complications can raise the risk of chronic post-operative pain (CPP). Recently promising results regarding CPP have been published in patients with Lateral Inguinal Hernia (LIH) using a slowly resorbable mesh in Lichtenstein technique. For this reason the aim of the present study was to find the effect of a slowly resorbable implant on the long-term rate of hernia recurrence and chronic post-operative pain in patients with LIH repaired with TEP procedure.MethodsProspective pilot study of TEP repair using TIGR® Matrix Surgical Mesh in 35 primary LIH. At 3-year follow-up the Visual Analogue Scale (VAS) and the Inguinal Pain Questionnaire were employed to assess pain. Recurrence was determined by ultrasound and clinical examination.ResultsAll patients completed the pain questionnaires but one patient did not attend the planned clinical examination for the 3-year follow-up. No patients had CPP, as defined in the World Guidelines for Groin Hernia Management. Almost all patients had lower VAS score in any activity 3 years following surgery in comparison to the preoperative period. Three patients (8.8%) suffered symptomatic recurrence during the 3-year follow-up.ConclusionTEP repair in patients with LIH using a synthetic long-term resorbable mesh was found to be encouraging respecting chronic post-operative pain at 3-year follow-up but at the cost of an increased risk of recurrence.

Conduite à tenir devant une douleur neuropathique après chirurgie du genou

Chronic postsurgical pain (CPSP) is experienced by 10 to 30% of individuals after classical operations. After knee surgery, epidemiology of CPSP varies between 16 to 20% of patients. Among these persistent pains without infection, mechanic injury or algodystrophy, the frequency of neuropathic pain is important. Neuropathic pain is due to nerve injury or impaired pain modulation with central sensitization. Variables that were commonly associated with a greater risk of chronic postoperative pain included greater preoperative pain, other pain sites, acute postoperative pain severity, psychological factors indicating negative affect, cognitive factors as catastrophism and comorbidities. The diagnosis is clinic and early detection is the better way to reduce chronic pain. The management of CPSP is based on preventive strategies and treatment of neuropathic pain. After knee surgery, first-line treatment of neuropathic pain coud be transcutaneous electrical nerve stimulation and lidocain patch, associated to tramadol. If insufficient, the recommended treatments are antidepressants, pregabalin and gabapentin, then capsaicin high-concentration patches in thrird line and strong opioids in last line. A rehabilitation programme and physical activity are strongly recommended. Several intervention strategies exist to address psychological distress or cognitive and emotional variables.

Analgesic treatment with pregabalin does not prevent persistent pain after peripheral nerve injury in the rat

Reducing the risk of chronic postoperative pain through preventive analgesia is an attractive therapeutic concept. Because peripheral nerve lesions are a major cause of chronic pain after surgery, we tested in rats whether analgesic treatment with pregabalin (PGB) has the capacity to mitigate the development of persistent neuropathic pain-like behavior. Starting on the day of spared nerve injury or 1week later, we treated rats with a continuous intrathecal infusion of PGB (300 or 900μg/24hours) or vehicle for up to 28days. Rats receiving early PGB treatment had almost normal withdrawal thresholds for punctate mechanical stimuli and were clearly less sensitive to pinprick or cold stimulation. The responses to punctate mechanical and cold stimulation were still reduced for a brief period after the infusion was terminated, but the difference from vehicle-treated rats was minor. Essentially, the analgesic effect of PGB was limited to the duration of the infusion, whether analgesia started at the time of surgery or with a delay of 1week, independently of the length of the treatment. PGB did not suppress the activation of spinal microglia, indicating that analgesia alone does not eliminate certain pain mechanisms even if they depend, at least partially, on nociceptive input. Unexpectedly, intrathecal infusion of PGB did not inhibit the nerve injury-induced accumulation of its binding target, the voltage-gated calcium channel subunit α2δ1, at primary afferent terminals in the spinal cord. Interference with the synaptic trafficking of α2δ1 is not required to achieve analgesia with PGB.

Identification du risque de douleur chronique après hépatectomie pour don de foie par les trajectoires de douleur

ObjectivesTo assess pain trajectories in predicting risk of chronic postoperative pain (CPP) after liver resection for living donor transplantation. Study designRetrospective analysis of patients undergoing liver resection for living donor transplantation during 3years. Patients and methodsAfter recording perioperative data, patients presenting CPP at 3months were separated from patients without postsurgical pain problem in order to build a pain trajectory for liver donor patients without CPP. Postoperative course of liver donors with CPP was then compared to that standard pain trajectory. ResultsSixty-five patients (30 females, 35 males) were included. Epidural analgesia was used in 66%; others received autocontrolled analgesia by morphine. Severe acute pain was expressed by 11% and 37% at rest and movement respectively on the first day. Chronic pain involved six patients without any link with gender or type of analgesia. Analysis of pain trajectories shown that these patients presented either higher initial pain at day 1 or positive slopes with worsening of pain. ConclusionAcute postoperative pain is a risk factor of developing CPP. Identification of those people by pain trajectories can be useful to treat them early.

Psychosocial factors appear to predict postoperative pain: Interesting, but how can such information be used to reduce risk?

Psychosocial factors have emerged as consistent predictors of acute and chronic postoperative pain, exerting at least moderate effects on these outcomes. Factors identified involve negative affectivity, stress and distress, and poor coping, suggesting that perceptual/cognitive, emotional, and behavioral factors play key roles in influencing postoperative pain. Building on research documenting such effects, we illustrate 2 pathways by which information on preoperative psychosocial factors (using pain catastrophizing as an example) can be used to advance research and clinical agendas. One pathway treats pain catastrophizing as an empiric marker of risk. We computed mean effect sizes (Cohen's D) linking pain catastrophizing to acute and chronic postsurgical pain and illustrate that a patient scoring above the median on a pain catastrophizing scale may incur twice the risk of developing chronic postsurgical pain than a patient below the median. The second pathway involves reducing the maladaptive patterns of pain-related thoughts and beliefs of a high pain catastrophizer via cognitive-behavioral therapies (CBT) to reduce the risk of chronic postoperative pain. By mapping effect sizes of CBT for reducing catastrophizing onto effect sizes of catastrophizing predicting pain, our calculations suggest that treating high catastrophizers with CBT may result in 50% fewer patients developing chronic postsurgical pain within this group. Thus, a definable and achievable amount of reduction in pain catastrophizing may translate into definable and achievable decreases in risk of chronic postoperative pain. Future research directions are outlined.

INGUINAL HERNIOPLASTY

Introduction: Chronic pain following inguinal hernia repair is becoming a significant clinical problem, involving increased numberof patients and surgeons. Much controversy exists regarding treatment. Elective division of the nerves has been proposed to reduce the riskof chronic post operative pain. O b j e c t i v e s : To evaluate the effectiveness of elective neurectomy during open hernia mesh repair, in reducingpostoperativ pain. Materials a n d m e t h o d s : Settings: All patients admitted in SUN department of surgery, Allied Hospital Faisalabad wereincluded in study. Study was started after the approval of synopsis on with inguinal hernia 2n d Feb, 2007 to Aug, 2007.100 patients of inguinalhernias were divided into 2 groups, 50 in each group i.e. group A & group B. The last patient was registered in the first week of July,convenience nonprobability sampling was used for location of patients in two groups. Results: On day one the pain was assessed in the twogroups i.e. Group A and group B (convenience non probability sampling technique used for patient grouping).It was found to be absent in 24/50(48 %) and 18/50 (36 %), mild in 10/50 (20 %) and 12/50 (24 %), it was moderate in10/50 (20 %) and 10/50 (20 %) and was severe in 6/50(12%) and 10/50 (20%) in the two groups respectively. One week after operation, in groups A and B, respectively, pain assessed with the useof the 4-point verbal scale was absent in 45 patients (90%) and 37 patients (74%), mild in 3/50 (6%) and 4/50 (8%), moderate in 2/50 (4%) and6/50 (12%), and severe in none and 3/50 (6%). Postoperative pain was not correlated with the presence of preoperative pain, and no correlationwas evidenced in the 2 subgroups. One month after operation, follow-up visits were performed in group A patients and group B patients. Inparticular, pain was absent in 46/50 (92%) patients in group A and 41/50 (82%) patients in group B. It was mild in 2 (6%) and 6/50 (12 %),moderate in 2/50 (4%) and 2/50 (4 %) none of the patients with elective neurectomy had pain at follow up of one month and 1 (2 %)one patientwithout elective neurectomy had pain. The numbness was assessed by checking sense of touch around the operated area. The difference foundbetween the 2 groups with respect to the presence of numbness was 15/50 (30 %) and 7/50 (14%) in the two groups i.e. group A and groupB respectively at day 1 and 12/50 (24%) and 7/50 (14%) at follow up of one week and it was 5/50 (10%) and 2/50(4%) at one month in the twogroups. C o n c l u s i o n s : When performing lichtenstein inguinal hernia repair, routine ilioinguinal, iliohypogastric and genital branch ofgenitofemoral nerves neurectomy is a reasonable option.

La douleur chronique après cure chirurgicale de hernie inguinale

Herniotomy is one of the most frequent surgical procedures. From the literature, it can be established that chronic postoperative pain affects from 3 to 45% of patients after 3 months, mainly lightly. However, most studies are retrospective, only a few are prospective or controlled, and almost none of them provides a clear description of pain characteristics. It seems that use of local-regional anaesthesia reduces the risk of chronic postoperative pain, and that laparoscopy or herniorraphy leads to less frequent postoperative pain in the long-term. Risk factors for chronic postoperative pain comprise inguinal pain before surgery, the type of surgical procedure and intraoperative nerve damage. Quantitative and electrophysiologic studies recently showed that almost all patients exhibit impairment of genitofemoral nerve function after surgery, irrespective of the actual procedure. However, patients experiencing chronic pain exhibited a more pronounced reduction of mechanical and thermal thresholds on the operated side than pain free patients, suggesting the neuropathic nature of chronic postoperative pain. Further studies are needed to establish clearly a classification of the characteristics and causes of pain after surgical repair of inguinal hernia.

Fibrin Sealant versus Use of Tackers for Fixation of Mesh in Laparoscopic Inguinal Hernia Repair

Background: Laparoscopic fixation of meshes prior to their fibrous incorporation should be reliable to minimize recurrences following transabdominal preperitoneal hernia repair (TAPP) and totally extraperitoneal repair (TEP) repair of inguinal hernias. However, suture, tack and staple-based fixation systems are associated with postoperative chronic inguinal pain. Initial fixation with fibrin sealant offers an atraumatic alternative, but there is little data showing that fibrin-based mesh adhesion provides adequate biomechanical stability for repair of inguinal hernia by TAPP and TEP. Methods: A literature search was performed using medline and the search Google, Springer link and Highwire press. The following search terms were used: Laparoscopic hernia mesh, Fibrin glue, and Tackers. 2293 citations were found in total.Selected papers were screened for further references. Criteria for selection of literature were the number of cases (excluded if less than 80), methods of analysis (statistical or nonstatistical), operative procedure (only universally accepted procedures were selected) and the institution where the study was done (specialized institution for laparoscopic surgery). Results: Mesh fixation has always invited lots of interest amongst surgeons and instrument companies due to the wide range of postoperative complications each of them caused. TAPP and TEP usually involves fixation of mesh, however many studies challenging the mesh fixation in TEP are being published. There are two most common methods of fixing mesh using fibrin glue (Tissucol) and tackers. Fibrin sealant possesses both mechanical strength and elasticity. Overall, data from previous studies, shows that mesh stability with fibrin sealant fixation is at least equivalent to suture fixation, indicating that fibrin sealant could be considered the fixation method of choice in inguinal hernia repair. This new method of mesh fixation is obviously potentially less harmful than stapling the mesh and can help reduce the risk of chronic postoperative pain at a comparative or even lower cost than a stapling device. Conclusions: Fibrin glue gives an adequate mesh fixation with a less chance of chronic postoperative pain. It appears to be an alternative to staples and may help reduce the postoperative pain problems after hernia repair. All methods give the same results in terms of recurrence rate, hospital stay, and costs; but with better results in terms of postoperative pain, seromas, and trocar-related trauma. However the use of fibrin glue needs extensive study, as the anatomical dissection and inguinal region preparation have to be carefully performed, and the mesh size has to be adequate; peritoneum closure with a running suture is more time consuming. Large randomized trials and longer follow-up are required to demonstrate the advantages of either technique.

Prevalence, characteristics, and predictors of chronic nonanginal postoperative pain after a cardiac operation: A cross-sectional study

This study was designed to assess the prevalence, characteristics, effect, and predictors of chronic postoperative pain 1 to 3 years after cardiac surgery. Seven hundred thirty-six patients who underwent coronary artery bypass surgery, valve replacement, or both between 1999 and 2002 were mailed questionnaires (response rate, 79% [n = 579]; 564 questionnaires were analyzed), and their hospital records were reviewed. Nonanginal chronic postoperative pain affected 23% of patients. Eighty percent of them had pain 1 or more days per week. The worst and usual pain intensities during the week preceding the survey reached moderate to severe levels (> or =4/10) in more than half of the patients. Thirty-one percent of the patients with chronic postoperative pain had taken analgesic pain medication during that week. During the same period, pain interfered significantly (> or =4/10) with various aspects of patients' daily life (eg, general activity level: 39.1%, sleep: 36.7%). When patients with and without chronic postoperative pain were compared, the former group had significantly higher levels of anxiety and depression, and they perceived their health-related quality of life as more compromised. Multivariate logistic regression analysis revealed that greater analgesic needs in the first few days postoperatively were associated with an increased risk of chronic postoperative pain. The only other significant factor was the time elapsed from surgical intervention to survey: the longer it was, the less likely the patients were to report chronic postoperative pain. The prevalence, severity, and effect of chronic postoperative pain after cardiac surgery should not be underestimated. Longitudinal prospective studies are needed to further evaluate risk factors, including inadequate postoperative pain relief in the acute period.