Arnaud Steyaert

Chronic postsurgical pain.

Purpose of review Chronic postsurgical pain (CPSP) is the consequence of acute postoperative pain. Unfortunately, despite many attempts of improvement, the treatment of acute postoperative pain remains unsatisfactory. In the present review, the probable reasons for this will be reviewed. Recent findings Based on the demonstration of specific, patients-related ‘pain risk’, individual pain trajectories and the importance of secondary hyperalgesia in the development of CPSP, new methods have to be applied in order to determine the real efficacy of new analgesic adjuvants. The key importance of the early inflammatory reaction in the genesis of the ‘postoperative syndrome’ and its close interaction with the mechanisms elicited by intraoperative opioid administration must also be outlined. Summary A single treatment approach is almost unlikely to solve the problem of CPSP. Consequently, the management of postoperative pain has to become more patients’ specific and etiologies sensitive.

Does the perioperative analgesic/anesthetic regimen influence the prevalence of long-term chronic pain after mastectomy?

STUDY OBJECTIVE To investigate if the anesthetic/analgesic regimen is associated with the risk of reporting long-term chronic postmastectomy pain (CPMP). DESIGN Cross-sectional survey SETTING Academic hospital PATIENTS A total of 267 women having undergone mastectomy with axillary lymph node dissection between 2003 and 2008 INTERVENTIONS: All patients were contacted between October and December 2012, with a questionnaire asking for persistent pain after surgery and its characteristics. MEASUREMENTS Besides demographical data, tumor characteristics, and adjuvant treatment, we recorded type and doses of intraoperative anesthetics/analgesics (sufentanil, ketamine, clonidine, nonsteroidal anti-inflammatory drugs, MgSO4, propofol, or halogenated agents). RESULTS Of the 128 patients returning analyzable questionnaires, 43.8% reported chronic pain (48.2% with neuropathic characteristics). Multivariate logistic/linear regression model showed 4 factors independently associated with persistent pain: recall of preoperative pain (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.09-1.48), chemotherapy (OR, 1.32; 95% CI, 1.13-1.55), need for strong opioids in postanesthesia care unit (OR, 1.30; 95% CI, 1.11-1.53), and halogenated agent anesthesia (OR, 0.81; 95% CI, 0.70-0.95). CONCLUSION In conclusion, our study confirms the high prevalence of CPMP, 4 to 9 years after surgery. Recall of preoperative pain, chemotherapy, and need for strong opioids in the postanesthesia care unit were all associated with the presence of chronic pain. Of the intraoperative analgesics/anesthetics studied, only use of halogenated agents was associated with a lower prevalence of CPMP.

Postoperative opioids: let us take responsibility for the possible consequences.

Anaesthesiologists involved in Acute Postoperative Pain Services and working in Emergency Departments are currently under pressure to provide their patients with the most effective therapy. Despite our efforts, international audits have highlighted the fact that acute pain still remains a problem for a substantial number of patients. Apart from the humanitarian aspect, severe unrelieved acute pain can compromise recovery after a surgical procedure or trauma, and in some patients may lead to the development of persistent pain. In the present issue of the European Journal of Anaesthesiology, Stromer et al. discuss the perioperative pain management of patients with opioid abuse, which is often challenging. They provide us with an opportunity to question our practice, and specifically our responsibility, in the prescription of postoperative opioids.

Pain, Quality of Life, and Clinical Outcomes after Robotic Lobectomy.

Background To evaluate pulmonary function, pain, and quality of life at midterm after robotic lobectomy performed in a single institution. Methods Sixty‐five consecutive patients underwent robotic thoracic surgery over 32 months using a complete four‐arm portal technique. Sixty‐one patients underwent lobectomies predominantly for stage I non‐small cell lung cancer. Pulmonary function tests were repeated at midterm follow‐up. Pain and quality of life were evaluated during the follow‐up on a subgroup of 39 patients, excluding the learning period. Results At a mean of 7‐month follow‐up, there was no significant difference in preoperative and midterm postoperative pulmonary function. A total of 62.5% of the patients reported a variable intensity of discomfort or pain at the surgical site, with a mean pain intensity score of 2.1 ± 1.4. Mean pain interference score were weak (1.8 ± 1.9), with patients with moderate pain reporting significantly higher pain interference scores than those with mild pain (p = 0.0025). Only one patient suffered from neuropathic‐like pain. Quality of life was globally favorable and related to the pain level, with a significant interference on the physical component. Conclusion Robotic lobectomy does not appear to have an impact on midterm pulmonary function. Persistent postoperative pain is mild, nonneuropathic‐like, with weak interference on daily activities. Quality of life is satisfactory but related to the pain level.

Feasibility of Topical Applications of Natural High-Concentration Capsaicinoid Solutions in Patients with Peripheral Neuropathic Pain: A Retrospective Analysis

Background. Capsaicin, one of several capsaicinoid compounds, is a potent TRPV1 agonist. Topical application at high concentration (high concentration, >1%) induces a reversible disappearance of epidermal free nerve endings and is used to treat peripheral neuropathic pain (PNP). While the benefit of low-concentration capsaicin remains controversial, the 8%-capsaicin patch (Qutenza®, 2010, Astellas, Netherlands) has shown its effectiveness. This patch is, however, costly and natural high-concentration capsaicinoid solutions may represent a cheaper alternative to pure capsaicin. Methods. In this retrospective study, 149 patients were screened, 132 were included with a diagnosis of neuropathic pain, and eighty-four were retained in the final analyses (median age: 57.5 years [IQR25–75: 44.7–67.1], male/female: 30/54) with PNP who were treated with topical applications of natural high-concentration capsaicinoid solutions (total number of applications: 137). Indications were postsurgical PNP (85.7%) and nonsurgical PNP (14.3%) (posttraumatic, HIV-related, postherpetic, and radicular PNP). Objectives. To assess the feasibility of topical applications of natural high-concentration capsaicinoid solutions for the treatment of PNP. Results. The median treated area was 250 cm2 [IQR25–75: 144–531]. The median amount of capsaicinoids was 55.1 mg [IQR25–75: 28.7–76.5] per plaster and the median concentration was 172.3 μg/cm2 [IQR25–75: 127.6–255.2]. Most patients had local adverse effects on the day of treatment, such as mild to moderate burning pain and erythema. 13.6–19.4% of the patients experienced severe pain or erythema. Following treatment, 62.5% of patients reported a lower pain intensity or a smaller pain surface, and 35% reported a sustained pain relief lasting for at least 4 weeks. Conclusion. Analgesic topical treatment with natural high-concentration capsaicinoid is feasible and may represent a low cost alternative to alleviate PNP in clinical practice.

Prevention and Treatment of Chronic Postsurgical Pain: A Narrative Review

Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process—involving multiple mechanisms at different levels—the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.