Neurophysiological characterization of persistent pain after laparoscopic inguinal hernia repair

Purpose  

About 2–5% of patients undergoing laparoscopic inguinal repair experience persistent pain influencing everyday activities. However, compared with persistent pain after open repair, the combined clinical and neurophysiological characteristics have not been described in detail. Thus, the aim of the study was to describe and classify patients with severe persistent pain after laparoscopic herniorrhaphy.     

A survey of patients' understanding and expectations of persistent postsurgical pain in a preoperative testing center

Study ObjectiveAcute postoperative pain may transition to persistent/chronic pain in up to 50% or more of patients after certain surgeries. Despite this concern, it is unclear that patients' preprocedure understanding and expectations are aligned with these potential outcomes. This study was designed to evaluate the extent of this alignment and the potential impact on the quality of risk/benefit discussions before procedures.DesignProspective survey.SettingA large, tertiary care preoperative assessment clinic.PatientsA total of 1481 adult patients.InterventionsSurvey administration.MeasurementsThe survey items evaluated patients' expectations of postoperative pain and how familiar patients were with the risk of persistent postsurgical pain based on their specific characteristics and procedure type.Main ResultsThe overwhelming majority (80%) of patients were unaware of the risk of persistent postsurgical pain. Given the choice, most patients (65%) wanted to be informed of their risk, and 25% stated that it might even affect their decision to proceed with surgery.ConclusionsThere is great need for health care providers to discuss the significant risk of persistent postsurgical pain with patients in the preoperative setting. Patients need to be armed with realistic data to ensure high-quality discussions of risk/benefit, align expectations with outcomes, and potentially identify high-risk groups in which preoperative intervention can reduce the likelihood or severity of persistent postoperative pain syndromes.     

Management of persistent groin pain after transobturator slings

Prolonged groin pain after transobturator tape is uncommon. Three women reported groin pain that had not improved by 3 months postoperatively. Combined steroid and local anesthetic was effective for pain relief in all patients. The differential diagnosis of persistent groin pain after transobturator tape includes adductor muscle strain, osteitis pubis, obturator/groin abscess, structural adhesions, and inflammation, edema or nerve entrapment of the anterior branch of the obturator nerve. No side effects of treatment were noted. Patients that do not respond to local injection may require mesh dissection and excision.     

Long-term follow-up after mesh removal and selective neurectomy for persistent inguinal postherniorrhaphy pain

Purpose

Persistent inguinal pain, influencing daily activities, is seen in about 5 % of patients following inguinal herniorrhaphy. Surgical treatment of patients with persistent postherniorrhaphy pain has been associated with pain relief and improvement in functional status. However, the detailed long-term outcome effects remain to be clarified. The aim of this study was to determine the long-term effects of mesh removal and selective neurectomy in patients with persistent postherniorrhaphy pain after previous open repair.

Methods

The study consecutively included 54 inguinal postherniorrhaphy pain patients treated with mesh removal and aimed neurectomy. Patients completed questionnaires evaluating pain intensity with a numerical rating scale (NRS) and pain-related functional impairment preoperatively, and, 3, 6, 12, 24, and 36 months postoperatively. Endpoints were changes in pain intensity and functional ability when comparing preoperative and postoperative assessments.

Results

Pain intensities (average, maximum, and during activity) were significantly lower at all time points during follow-up compared to preoperative values (p < 0.01 for all) with a reduction in median (IQR) average pain intensity from 6.0 (5.0–7.0) preoperatively to 3.0 (1.0–5.5) at 36-month follow-up. There was no association between positive pain outcome and intraoperative nerve identification (p = 0.47). The number of patients who reported a long-term negative effect of the operation (≥25 % increase in average pain intensity at 36-month follow-up) was 1 of 8. The functional ability was improved at 3 months after the operation (p < 0.01), but the improvement was not statistically significant in the follow-up period. Preoperative signs of depression, anxiety, and catastrophizing had no influence on outcome.

Conclusions

Mesh removal and attempted neurectomy may provide long-lasting analgesic effects in most patients and with a small proportion being worse, without relation to pain history and operative findings. Detailed multicenter collaboration is required to define preoperative diagnostics and the indication for mesh removal and neurectomy, the exact surgical procedure (type of neurectomy) and with detailed follow-up.     

Quantitative validation of sensory mapping in persistent postherniorrhaphy inguinal pain patients undergoing triple neurectomy

Hernia - Neurectomy of the inguinal nerves may be considered for selected refractory cases of chronic postherniorrhaphy inguinal pain (CPIP). There is to date a paucity of easily applicable...     

Canadian survey of postsurgical pain and pain medication experiences

PURPOSE: To assess the postoperative pain and pain medication experiences of Canadians. METHODS: Three hundred and five general population subjects from across Canada who had surgery in the previous three years were retrospectively questioned regarding pain experiences in the surgical facility and at home, pain medication efficacy and pain medication satisfaction. RESULTS: While in the surgical facility, pain was experienced by 68% of patients who expected overnight admission ("inpatients") and 49% of patients who expected same-day discharge ("outpatients"). Overall, 47% of inpatients and 15% of outpatients reported that their highest experience of pain was severe or extreme; 25% of inpatients and 9% of outpatients reported that their average pain was severe or extreme. In the two weeks post-discharge, 79% and 74% respectively of inpatients and outpatients experienced pain. Severe or extreme pain occurred at home in 25% of inpatients and 28% of outpatients; average pain was severe or extreme for 9% of inpatients and 12% of outpatients. Complete or a lot of pain relief was experienced by 54% to 72% patients who received pain medication; higher rates of pain medication satisfaction were reported than rates of pain relief from pain medication. CONCLUSION: Severe or extreme pain was experienced by many surgical patients. Improvements could be made to patients' postsurgical pain experience in Canada, both in the surgical facility and subsequent to discharge.     

Pulsed radiofrequency in the treatment of persistent pain after inguinal herniotomy: a systematic review

In the United States, it is estimated that between 6000 and 18,000 individuals each year present with disabling pain after inguinal hernia repair. Although surgical treatment with mesh removal is one of few options available, effective alternatives to nonsurgical management are needed. The use of pulsed radiofrequency (PFR), leading to nondestructive lesions of nerve structures, has been proposed as a treatment option. To examine the evidence of treatment efficacy, a systematic literature search was made. From the databases PubMed, Embase, and CINAHL, 4 case reports were retrieved and 8 patients were included for analysis. The PFR treatment was peripheral (n = 4) and central (n = 4). Pain relief varied between 63% and 100%, the follow-up period was 3 to 9 months, and no adverse effects or complications were reported. In conclusion, the evidence base of PRF in persistent pain after inguinal herniotomy is fairly limited. Suggestions for improved research strategies are presented.     

Epidural sufentanil for postsurgical pain relief

This study aimed to determine the safest and most effective dose of sufentanil for epidural administration to relieve post-operative pain. Thirty healthy patients were treated following abdominal surgery. They received no opiates in premedication nor peroperatively. After surgery, upon occurrence of pain, they received a single epidural injection of sufentanil (30, 50 or 75 micrograms) according to a randomized protocol. Pain intensity was evaluated using a visual analogue scale (VAS). Arterial blood gases, peak flow (PF) and forced vital capacity (FVC) were measured before, and at 1, 2 and 4 h post-operatively. The onset of the analgesic effect was evident within 5 min, and was significantly faster with 75 micrograms sufentanil than with either of the other two doses (P less than 0.05). The maximal effect occurred at 30 min, and lasted for 4 h (VAS less than 5) irrespective of the dose injected. Respiratory rate decreased at most by 24% and post-operative sedation was increased for approximately 2 h, both effects being dose-related. Arterial PCO2, heart rate and mean arterial pressure remained normal. Two hours after the injection, there was a small increase in FVC and PF.     

Combination tramadol plus acetaminophen for postsurgical pain

BACKGROUND: This multicenter, randomized, double-blind, active- and placebo-controlled trial evaluated tramadol plus acetaminophen (APAP) for orthopedic (n = 153) and abdominal (n = 152) postsurgical pain. METHODS: Patients with moderate pain or greater were randomized to an initial two tablets of 37.5 mg tramadol plus 325 mg APAP (n = 98), codeine 30 mg plus APAP 300 mg (n = 109), or placebo (n = 98); thereafter, they received 1 to 2 tablets every 4 to 6 hours as needed for pain for 6 days. Outcome measures were pain relief and pain intensity, total pain relief, sum of pain intensity differences, and sum of pain relief and pain intensity differences during 4 hours and the daily averages. RESULTS: Tramadol plus APAP was superior to placebo for total pain relief, sum of pain intensity differences, and sum of pain relief and pain intensity differences (P < or =0.015); tramadol plus APAP and codeine plus APAP did not separate (P > or=0.281). For average daily pain relief, average daily pain intensity, and overall medication assessment, tramadol plus APAP was superior to placebo (P < or =0.038); codeine plus APAP did not separate from placebo (P > or =0.125). Discontinuation because of adverse events occurred in 8.2% of tramadol plus APAP, 10.1% of codeine plus APAP, and 3.0% of placebo patients. Except for constipation (4.1% tramadol plus APAP vs 10.1% codeine plus APAP) and vomiting (9.2% vs 14.7%, respectively), adverse events were similar for active treatments. CONCLUSIONS: Tramadol plus APAP (mean dose 4.4 tablets) was effective and well tolerated for postsurgical pain and showed better tolerability than did codeine plus APAP.     

Ulcerative colitis of the neovagina as a postsurgical complication of persistent cloaca

Persistent cloaca is characterized by a common vestibule connected to the bladder, uterus, and rectum and a single perineal orifice to the exterior. Treatment can involve vaginal reconstruction with sigmoid/descending colon. We report a case of an 8-year-old girl who, as an infant, underwent vaginoplasty using sigmoid colon for persistent cloaca and developed a fulminant colitis that also affected the colonic neovagina 2 years after her reconstruction.