Julie Bruce

A review of chronic pain after inguinal herniorrhaphy.

BackgroundChronic pain was believed to be a recognized but infrequent complication after inguinal hernia repair. Evidence suggests that patients with chronic pain place a considerable burden on health services. However, few scientific data on chronic pain after this common elective operation are available. ObjectivesTo review the frequency of chronic pain and to discuss etiological theories and current treatment options for patients with chronic post herniorrhaphy pain. Materials and MethodsAll studies of postoperative pain after inguinal hernia repair with a minimum follow-up period of 3 months, published between 1987 and 2000, were critically reviewed. Results and DiscussionThe frequency of chronic pain after inguinal hernia repair was found to be as high as 54%, much more than previously reported. Quality of life of these patients is affected. Chronic pain is reported less often after laparoscopic and mesh repairs. Recurrent hernia repair, preoperative pain, day case surgery, delayed onset of symptoms, and high pain scores in the first week after surgery, however, were identified to be risk factors for the development of chronic pain. Definition of chronic pain was not explicit in the majority of the reviewed studies. Accurate evaluation of the frequency of chronic pain will require standardization of definition and methods of assessment. Prospective studies are required to define the role of risk factors identified in this review.

Long-term follow-up of breast cancer survivors with post-mastectomy pain syndrome

Post-mastectomy pain syndrome (PMPS) is a recognised complication of breast surgery although little is known about the long-term outcome of this chronic pain condition. In 1996, Smith et al identified a prevalence rate of PMPS of 43% among 408 women in the Grampian Region, Northeast Scotland. The aim of this study was to assess long-term outcome at 7–12 years postoperatively in this cohort of women, to describe the natural history of PMPS and impact of pain upon quality of life. Chronic pain and quality of life were assessed using the McGill Pain Questionnaire (MPQ) and Short Form-36 (SF-36). Of 175 women reporting PMPS in 1996, 138 were eligible for questionnaire follow-up in 2002. Mean time since surgery was 9 years (s.d. 1.8 years). A response rate of 82% (113 out of 138) was achieved; 59 out of 113 (52%) women reported continued PMPS and 54 out of 113 (48%) women reported their PMPS had resolved since the previous survey in 1996. Quality of life scores were significantly lower in women with persistent PMPS compared to those women whose pain had resolved. However, for women with persistent PMPS, SF-36 scores had improved over time. Risk factors for persistent PMPS included younger age and heavier weight. This study found that, of women reporting PMPS in 1996, half of those surveyed in 2002 continued to experience PMPS at a mean of 9 years after surgery.

Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain.

Objectives:Anxiety and pain catastrophizing predict acute postoperative pain. However, it is not well established whether they also predict chronic postsurgical pain (CPSP). The aim of this systematic review and meta-analysis was to investigate whether high levels of preoperative anxiety or pain catastrophizing are associated with an increased risk of CPSP. Methods:Electronic search databases included PubMed and PsychINFO. Additional literature was obtained by reference tracking and expert consultation. Studies from 1958 until October 2010, investigating the association between preoperative anxiety or pain catastrophizing and CPSP in adult surgery patients, were assessed. The primary outcome was the presence of pain at least 3 months postoperatively. Results:Twenty-nine studies were included; 14 instruments were used to assess anxiety or pain catastrophizing. Sixteen studies (55%) reported a statistically significant association between anxiety or pain catastrophizing and CPSP. The proportion of studies reporting a statistically significant association was 67% for studies of musculoskeletal surgery and 36% for other types of surgery. There was no association with study quality, but larger studies were more likely to report a statistically significant relationship. The overall pooled odds ratio, on the basis of 15 studies, ranged from 1.55 (95% confidence interval, 1.10-2.20) to 2.10 (95% confidence interval, 1.49-2.95). Pain catastrophizing might be of higher predictive utility compared with general anxiety or more specific pain-related anxiety. Discussion:There is evidence that anxiety and catastrophizing play a role in the development of CPSP. We recommend that anxiety measures should be incorporated in future studies investigating the prediction and transition from acute to chronic postoperative pain.

The prevalence of chronic chest and leg pain following cardiac surgery: a historical cohort study.

&NA; Chronic pain after surgery is recognised as an important post‐operative complication; recent studies have shown up to 30% of patients reporting persistent pain following mastectomy and inguinal hernia repair. No large‐scale studies have investigated the epidemiology of chronic pain at two operative sites following coronary artery bypass grafting (CABG). This paper reports the follow‐up of a cohort of 1348 patients who underwent cardiac surgery between 1996 and 2000 at one cardiothoracic unit in northeast Scotland. Chronic pain was defined as pain in the location of surgery, different from that suffered pre‐operatively, arising post‐operatively and persisting beyond 3 months. The survey questionnaire consisted of the short‐form‐36 (SF‐36), Rose angina questionnaire, McGill pain questionnaire and the University of California and San Francisco (UCSF) pain service questionnaire. Of the 1080 responders, 130 reported chronic chest pain, 100 chronic post‐saphenectomy pain and 194 reported pain at both surgical sites. The cumulative prevalence of post‐cardiac surgery pain was 39.3% (CI95 36.4–42.2%) and mean time of 28 months since surgery (SD 15.3 months). Patients who reported pain at both sites had lower quality of life scores across all eight health domains compared to patients with pain at one site only and those who were pain‐free. Prevalence of chronic pain decreased with age, from 55% in those aged under 60 years to 34% in patients over 70 years. Patients with pre‐operative angina and those who were overweight or obese (BMI≥25) at the time of surgery were more likely to report chronic pain. Chronic pain following median sternotomy and saphenous vein harvesting is more common than hitherto reported and that patients undergoing CABG should be warned of this possibility.

Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis

Objective To determine the relative effects of open healing compared with primary closure for pilonidal sinus and optimal closure method (midline v off-midline). Design Systematic review and meta-analyses of randomised controlled trials. Data sources Cochrane register of controlled trials, Cochrane Wounds Group specialised trials register, Medline (1950-2007), Embase, and CINAHL bibliographic databases, without language restrictions. Data extraction Primary outcomes were time (days) to healing, surgical site infection, and recurrence rate. Secondary outcomes were time to return to work, other complications and morbidity, cost, length of hospital stay, and wound healing rate. Study selection Randomised controlled trials evaluating surgical treatment of pilonidal sinus in patients aged 14 years or more. Data were extracted independently by two reviewers and assessed for quality. Meta-analyses used fixed and random effects models, dichotomous data were reported as relative risks or Peto odds ratios and continuous data are given as mean differences; all with 95% confidence intervals. Results 18 trials (n=1573) were included. 12 trials compared open healing with primary closure. Time to healing was quicker after primary closure although data were unsuitable for aggregation. Rates of surgical site infection did not differ; recurrence was less likely to occur after open healing (relative risk 0.42, 0.26 to 0.66). 14 patients would require their wound to heal by open healing to prevent one recurrence. Six trials compared surgical closure methods (midline v off-midline). Wounds took longer to heal after midline closure than after off-midline closure (mean difference 5.4 days, 95% confidence interval 2.3 to 8.5), rate of infection was higher (relative risk 4.70, 95% confidence interval 1.93 to 11.45), and risk of recurrence higher (Peto odds ratio 4.95, 95% confidence interval 2.18 to 11.24). Nine patients would need to be treated by an off-midline procedure to prevent one surgical site infection and 11 would need to be treated to prevent one recurrence. Conclusions Wounds heal more quickly after primary closure than after open healing but at the expense of increased risk of recurrence. Benefits were clearly shown with off-midline closure compared with midline closure. Off-midline closure should become standard management for pilonidal sinus when closure is the desired surgical option.

Psychological, surgical, and sociodemographic predictors of pain outcomes after breast cancer surgery: A population-based cohort study

Summary Risk factors for chronic pain up to 9 months after breast cancer surgery include younger age, psychological vulnerability, axillary clearance surgery, and severe acute postoperative pain. ABSTRACT Chronic postsurgical pain (CPSP) is a common postoperative adverse event affecting up to half of women undergoing breast cancer surgery, yet few epidemiological studies have prospectively investigated the role of preoperative, intraoperative, and postoperative risk factors for pain onset and chronicity. We prospectively investigated preoperative sociodemographic and psychological factors, intraoperative clinical factors, and acute postoperative pain in a prospective cohort of 362 women undergoing surgery for primary breast cancer. Intraoperative nerve handling (division or preservation) of the intercostobrachial nerve was recorded. At 4 and 9 months after surgery, incidence of chronic painful symptoms not present preoperatively was 68% and 63%, respectively. Univariate analysis revealed that multiple psychological factors and nerve division was associated with chronic pain at 4 and 9 months. In a multivariate model, independent predictors of CPSP at 4 months included younger age and acute postoperative pain (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.12 to 1.60), whereas preoperative psychological robustness (OR 0.70, 95% CI 0.49 to 0.99), a composite variable comprising high dispositional optimism, high positive affect, and low emotional distress, was protective. At 9 months, younger age, axillary node clearance (OR 2.97, 95% CI 1.09 to 8.06), and severity of acute postoperative pain (OR 1.17, 95% CI 1.00 to 1.37) were predictive of pain persistence. Of those with CPSP, 25% experienced moderate to severe pain and 40% were positive on Douleur Neuropathique 4 and Self‐Complete Leeds Assessment of Neuropathic Symptoms and Signs pain scales. Overall, a high proportion of women report painful symptoms, altered sensations, and numbness in the upper body within the first 9 months after resectional breast surgery and cancer treatment.

Procedure-specific surgical site infection rates and postdischarge surveillance in Scotland

OBJECTIVE To investigate the impact of postdischarge surveillance (PDS) on surgical-site infection (SSI) rates for selected surgical procedures in acute care hospitals in Scotland. DESIGN Prospective surveillance of SSI after selected surgical procedures. SETTING The Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP), which is based on the methodology of the Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance system (NNIS). Thirty-two of 46 acute care hospitals throughout Scotland contributed data to SSHAIP for this study. METHODS Data were from 21,710 operations that took place between April 1, 2002, and June 30, 2004; nine categories of surgical procedures were analyzed. CDC NNIS system definitions and methods were used for SSI PDS. PDS is a voluntary component of the mandatory SSI surveillance program in Scotland. PDS was categorized as none, passive, active without direct observation, and active with direct observation. RESULTS From our study information, PDS data were available for 12,885 operations (59%). A total of 2,793 procedures (13%) were associated with passive PDS and 10,092 (46%) with active PDS. The SSI rate among the 8,825 operations with no PDS was 2.61% (95% confidence interval [CI], 2.3%-3.0%), which was significantly lower than the SSI rate found among the 12,885 operations for which PDS was performed (6.34% [95% CI, 5.9%-6.8%]). For breast surgery, cesarean section, hip replacement, and abdominal hysterectomy, the rate of SSI when PDS was performed was significantly higher than that when PDS was not performed (P<.01 for each procedure). No differences in SSI rates were found for surgery to repair fractured neck of the femur or for knee replacement. SSI rates were examined according to procedure type, performance of PDS, and NNIS risk index; rates of SSI increased with NNIS risk index within procedure group and PDS group. Logistic regression analyses confirmed that procedure type, performance of PDS, and NNIS risk index were all statistically independent predictors of report of an SSI (P<.05). CONCLUSIONS This Scottish national data set incorporates a substantial amount of PDS data. We recommend a procedure-specific approach to PDS, with direct observation of patients after breast surgery, cesarean section, and hysterectomy, for which the length of stay is typically short. Readmission surveillance may be adequate to detect most SSIs after orthopedic surgery or vascular surgery, for which the length of stay is typically longer.

Chronic Pain After Surgery Time for Standardization? A Framework to Establish Core Risk Factor and Outcome Domains for Epidemiological Studies

Introduction and Objectives:Many studies have reported putative factors for the development of chronic pain after surgery. However, advances in knowledge about the etiology and prognosis of chronic postsurgical pain (CPSP) could be gained by improving methodology within studies of surgical pain. The purpose of this study was to review predictive factors and to propose core risk factor and outcome domains for inclusion in future epidemiological studies investigating CPSP. Methods:Using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials as a framework we reviewed risk factor and outcome domains, methodological issues and standardized measurement tools based on findings from narrative and systematic reviews, primary clinical and epidemiological studies and published guidelines for chronic pain clinical trials. Results:Five “core” risk factor domains (demographic, pain, clinical, surgery-related, and psychological) and 4 outcome domains (pain, physical functioning, psychological functioning, and global ratings of outcome) were identified. Important methodological issues, related to the definition and timing of follow-up to assess transition from acute to chronic pain are discussed. We also propose the use of validated, standardized measurement tools to capture risk factor and outcome domains at multiple time points. Discussion:There is potential to advance the field of CPSP research by striving for consensus among pain experts; this would advance current evidence by improving our ability to compare findings from different studies and would facilitate the aggregation of surgical cohort datasets to allow international comparisons. We propose these findings as a starting point to build a comprehensive framework for epidemiological studies investigating chronic pain after surgery.

Systematic review of the quality of surgical mortality monitoring

Mortality is the most tightly defined and used adverse event for audit and performance monitoring in surgery. However, to identify cause and therefore scope for improvement, accurate and timely data are required. The aim of this study was to perform a systematic review of the quality of measurement, reporting and monitoring of mortality as an outcome after surgery.

Psychological risk factors for chronic post-surgical pain after inguinal hernia repair surgery: A prospective cohort study

A significant proportion of patients experience chronic post‐surgical pain (CPSP) following inguinal hernia surgery. Psychological models are useful in predicting acute pain after surgery, and in predicting the transition from acute to chronic pain in non‐surgical contexts. This is a prospective cohort study to investigate psychological (cognitive and emotional) risk factors for CPSP after inguinal hernia surgery. Participants were asked to complete questionnaires before surgery and 1 week and 4 months after surgery. Data collected before surgery and 1 week after surgery were used to predict pain at 4 months. Psychological risk factors assessed included anxiety, depression, fear‐avoidance, activity avoidance, catastrophizing, worry about the operation, activity expectations, perceived pain control and optimism. The study included 135 participants; follow‐up questionnaires were returned by 119 (88.1%) and 115 (85.2%) participants at 1 week and 4 months after surgery respectively. The incidence of CPSP (pain at 4 months) was 39.5%. After controlling for age, body mass index and surgical variables (e.g. anaesthetic, type of surgery and mesh type used), lower pre‐operative optimism was an independent risk factor for CPSP at 4 months; lower pre‐operative optimism and lower perceived control over pain at 1 week after surgery predicted higher pain intensity at 4 months. No emotional variables were independently predictive of CPSP. Further research should target these cognitive variables in pre‐operative psychological preparation for surgery.