Is It Normal To Have Pain 8 Weeks After Herena Repair
Ann Surg. 2006 Aug; 244(2): 212–219.
Run a risk Factors for Long-term Pain After Hernia Surgery
Ulf Fränneby
From the *Department of Surgery, Södersjukhuset, Stockholm; †Section of Surgery, Akademiska Sjukhuset, Uppsala; ‡Department of Surgery, östersunds Sjukhus, östersund; §Section of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; and ∥Department of Surgery, Akademiska Sjukhuset, Uppsala, Sweden.
Gabriel Sandblom
From the *Department of Surgery, Södersjukhuset, Stockholm; †Department of Surgery, Akademiska Sjukhuset, Uppsala; ‡Department of Surgery, östersunds Sjukhus, östersund; §Section of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; and ∥Department of Surgery, Akademiska Sjukhuset, Uppsala, Sweden.
Pär Nordin
From the *Department of Surgery, Södersjukhuset, Stockholm; †Department of Surgery, Akademiska Sjukhuset, Uppsala; ‡Department of Surgery, östersunds Sjukhus, östersund; §Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; and ∥Section of Surgery, Akademiska Sjukhuset, Uppsala, Sweden.
Olof Nyrén
From the *Department of Surgery, Södersjukhuset, Stockholm; †Section of Surgery, Akademiska Sjukhuset, Uppsala; ‡Department of Surgery, östersunds Sjukhus, östersund; §Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; and ∥Section of Surgery, Akademiska Sjukhuset, Uppsala, Sweden.
Ulf Gunnarsson
From the *Department of Surgery, Södersjukhuset, Stockholm; †Department of Surgery, Akademiska Sjukhuset, Uppsala; ‡Department of Surgery, östersunds Sjukhus, östersund; §Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; and ∥Section of Surgery, Akademiska Sjukhuset, Uppsala, Sweden.
Abstract
Objective:
To estimate the prevalence of balance pain two to iii years after hernia surgery, to identify factors associated with its occurrence, and to appraise the consequences for the patient.
Summary Background Data:
Iatrogenic chronic pain is a neglected problem that may totally annul the benefits from hernia repair.
Methods:
From the population-based Swedish Hernia Register 3000 patients aged 15 to 85 years were sampled from the 9280 patients registered as having undergone a chief groin hernia performance in the year 2000. Of these, the 2853 patients still alive in 2003 were requested to fill up in a postal questionnaire.
Results:
After two reminders, 2456 patients (86%), 2299 men and 157 women responded. In response to a question about "worst perceived pain concluding week," 758 patients (31%) reported pain to some extent. In 144 cases (6%), the pain interfered with daily activities. Age below median, a loftier level of pain before the operation, and occurrence of any postoperative complication were found to significantly and independently predict long-term pain in multivariate logistic analysis when "worst pain final week" was used equally effect variable. The same variables, forth with a repair technique using anterior approach, were establish to predict long-term pain with "pain right at present" as outcome variable.
Conclusion:
Pain that is at least partly disabling appears to occur more often than recurrences. The prevalence of long-term pain tin be reduced past preventing postoperative complications. The bear upon of repair technique on the hazard of long-term hurting shown in our study should exist further assessed in randomized controlled trials.
Until recently, research on the results of hernia surgery has focused mainly on recurrences. However, with the introduction of mesh techniques and presumably an increased sensation of the importance of systematic quality command, the recurrence rate has decreased dramatically.1 Hence, now that recurrences are no longer a pressing clinical trouble, at that place has been a contempo upsurge in interest in chronic pain every bit an adverse consequence. But the level of quantification of pain has often been limited in studies addressing the adventure of long-term pain, and hurting has sometimes been treated merely as a dichotomous (aye/no) phenomenon.2 Every bit a result, the clinical and public health significance of reported prevalence rates of residual pain (ranging between 0% and 37%) remains uncertain.3
With the main purpose of evaluating long-term pain as an alternative endpoint in enquiry on the outcome of hernia surgery, we used a validated pain questionnaire to investigate hurting behavior rather than imaginary descriptors of hurting intensity in an essentially population-based serial of patients operated on 59 hospitals.
MATERIALS AND METHODS
In the Swedish Hernia Register (SHR),4 detailed information on more than than 100,000 groin hernia repairs has been compiled since 1992. Every inguinal or femoral hernia operation in patients of ages 15 years or older at participating departments are recorded according to a standardized protocol. Recorded variables include age, gender, manner of admission, time on waiting list, type of hernia every bit noted during performance, size of the defect, method of repair, postoperative complications and reoperation for recurrence.4 Methods of repair using anterior approach include Liechtenstein, Shouldice, Bassini, plug procedures, and other methods through groin incision. Methods of repair using posterior arroyo include laparoscopic, Stoppa, and Nyhus techniques. Information on clinical follow-upward is not mandatory, merely whatever complication observed past the operating unit of measurement up to thirty days afterwards surgery has to be recorded in the database.5 Every Swedish resident has a unique National Registration Number that is universally used in official contexts, including entries in population and wellness registers, as well as in medical case records. The National Registration Number makes follow-up possible through cross-linkages within the SHR and too through record linkages to the Swedish Crusade of Expiry Register (CDR) and the continuously updated and virtually complete national Inpatient Register.
Patients
Between January 1 and December 31, 2000, x,479 hernia operations at 59 hospitals, constituting 60% of all operating units in Sweden, were recorded in the SHR. Of these, 9280 were primary hernia repairs. Later on exclusion of patients with bilateral repairs, previous hernia operations on the contralateral side (served as reference for pain), subsequent hernia operations on either side, and patients beneath 15 years or above 85 years of age, 7828 patients were eligible for investigation. By cross-linkage with CDR (May 2002), 7536 patients were institute to be still alive. From this accomplice, we randomly selected 3000 patients who had undergone a unilateral repair of a primary inguinal or femoral hernia.
There were 2787 (92.9%) men and 213 (7.1%) women in the sample, with a hateful historic period of 58.two years. Before the questionnaires were mailed, a terminal record linkage with the CDR was performed in Jan 2003, and this revealed that 147 of these patients had died, leaving 2853 notwithstanding alive and available for contact (Table 1). These patients received a postal questionnaire about the occurrence and daily life consequences of inguinal pain before and after the operation. Two reminding letters were sent after 5 and 10 weeks, respectively, to those who had not responded.
Table 1. The Process of Patient Pick for the Study
Questionnaire
The cocky-recording instrument used in the questionnaire was a 7-step stock-still bespeak calibration with steps operationally linked to behavioral events, including additional monitoring of painduration, termed the "duration-intensity-behavior-scale" (DIBS). The DIBS scale has previously been evaluated regarding compliance, authenticity, reliability, and sensitivity amid patients with functional abdominal pain.half dozen By defining pain operationally in terms of behavior necessitated by the pain, the DIBS instrument escapes, at to the lowest degree to some extent, the dilemma of pain definition and standardization, and the bear on on daily life activities is easily inferred. Pain in the contralateral (thus not operated) groin was used as a reference. The entire questionnaire has too recently been validated (submitted manuscript) and found to have high validity and reliability equally an musical instrument for measuring chronic pain post-obit hernia surgery. The validation also included a comparison between the operated and contralateral groin. At that place was a baseline level of hurting in the contralateral groin, just the level of pain was significantly college in the operated groin.
Statistical Methods
Age-specific prevalence of pain in 10-yr age strata at the time of the questionnaire survey was expressed equally the number of patients with answers fulfilling our criteria of persistent hurting, divided by the total number of patients who gave interpretable answers in the respective historic period stratum. Nosotros calculated 95% confidence intervals (CI) co-ordinate to the method proposed by Wilson.7
Factors associated with rest pain were adamant in multivariate unconditional logistic regression models, with the following independent variables: age in quartiles based on the distribution among subjects with no hurting, sexual practice, hernia reducibility on admission (yes/no), type of hernia (lateral, medial, femoral, or combined), size of the defect (>/≤three cm), level of hurting earlier the functioning (≥/< "interferes with concentration on chores and activities"), method of repair (Shouldice, Lichtenstein, Plug techniques, other open mesh techniques, open preperitoneal mesh techniques, other open up mesh techniques, Trans Abdominal Pre Peritoneal laparoscopic repair [TAPP] and Total Extra Peritoneal laparoscopic repair[TEP]), techniques non involving exploration of the groin grouped together (TEP, TAPP, and open preperitoneal mesh techniques), recorded postoperative complications (yes/no), hernia surgery volume at the hospital (≥/<200 operations per year), and number of surgeons who performed the operation (1 or 2). The dependent variable was log (p/i − p), where p was the probability of having any pain (ie, "pain present simply tin can easily be ignored" or more). Dissever models were built for "pain right now" and "worst hurting last calendar week." The models were synthetic by stepwise selection with entry testing based on the significance of the score statistic, and removal testing based on the likelihood-ratio statistic.
Severe acute postoperative pain is also recorded in the register as a postoperative complication simply was not included in the analysis of risk factors for long-term hurting since the distinction between astute and chronic postoperative pain is non articulate plenty to define them every bit independent and dependent variables in the same multivariate model, ie, acute pain could be considered every bit office of the causal chain between the operative process and the development of chronic pain.
RESULTS
The distribution of answers is presented in Tabular array 2. After ii reminders, 2456 (86%) of the 2853 patients had responded (2299 men and 157 women). Their mean age at functioning was 58.2 years. Reasons for non returning the questionnaire were unknown address in 32 (1%) and failure to respond in the other 365 (13%). In that location was no divergence in age or in proportion of patients with complications or severe postoperative pain recorded in the SHR betwixt patients who responded and those who did not. Postoperative complications included wound infections (n = 34, 1.4%), hematoma (n = 111, 4.four%), severe hurting (n = 30, 1.2%), and other (n = 71, two.9%). Postoperative complications are defined according to the standards of the SHR.four The proportions of patients with residual hurting 24 to 36 months later on the functioning, stratified for historic period, technique of repair, type of hernia, size of hernia defect, level of pain earlier the performance, and postoperative complications are shown in Figures one and 2. Since some patients did not reply all questions, the numbers of patients are not identical for "hurting right now" and "worst pain last week."
FIGURE 1. Prevalence of balance hurting by age. Vertical bars signal 95% confidence intervals. Numbers in brackets on the x-axis indicate number of responders to the 2 corresponding questions.
Effigy 2. Prevalence of residual pain past technique of repair. Vertical bars indicate 95% confidence intervals. Numbers in brackets on the x-axis indicate number of responders to the two respective questions.
Table ii. Questionnaire and Results
TABLE 2. (Continued)
In answer to the question nearly "worst pain last week," 758 patients (31%; 95% conviction interval [CI], 29%–33%) reported some form of pain, whereas 144 (6%; 95% CI, v%–7%) had had severe pain that could non be ignored and interfered with their daily activities. When asked to judge the severity of pain before the functioning, 2091 (85%) reported some form of pain and 1220 (50%) severe pain. There was no significant association in type of repair and level of preoperative pain in χ2 analysis. In response to questions concerning daily activities, 82 (3.3%; 95% CI, two.7%–4.1%) stated that it was difficult to get up from a depression chair and 119 (four.viii%; 95% CI, iv.1%–5.8%) had difficulty in standing up for more than than 30 minutes and climbing stairs. In 193 patients (7.nine%; 95% CI, half dozen.9%–9.0%), the hurting limited their power to perform sports. Some period of sick-leave had to be taken by twenty patients (0.8%; 95% CI, 0.five%–1.3%) in the concluding 2 months and 6 patients (0.2%; 95% CI, 0.i%–0.5%) claimed to be receiving a disability pension for pain in the surgically treated groin. The number of patients yet at work in the cohort was 1937 (79%) (Tabular array iii).
TABLE 3. Results of Multivariate Logistic Analysis of Hazard Factors Predicting Any Level of Pain Versus No Hurting Regarding "Pain Right Now"
In multivariate logistic analysis, a loftier level of pain before the operation (odds ratio [OR], 2.one; 95% CI, 1.8-ii.6; P < 0.001) and postoperative complications (OR, i.viii; 95% CI, 1.2–2.5; P = 0.003) were constitute to significantly and independently predict balance pain, whereas "age above median" (OR, 0.vii; 95% CI, 0.5–0.8; P < 0.001) predicted a decrease in residual pain when "worst hurting last week" was used equally the effect variable. No specific technique of repair was significantly associated with an increased or decreased risk of rest hurting in either of the 2 multivariate analyses, but the number of patients with long-term pain was small in each category, thus prohibiting statistical ascertainment of annihilation but very marked relationships. When the techniques were grouped into those that did or did not involve autopsy of the groin, however, the latter techniques were associated with a significantly lower risk of long-term pain with "pain correct now" as outcome variable (OR, 0.half dozen; P = 0.033). When "worst pain last week" was used as the outcome variable, groin dissection was associated with a nonsignificant subtract of the risk for long-term pain.
DISCUSSION
Our results emphasize that balance hurting should be viewed as an essential endpoint when investing the outcome of hernia surgery. After 24 to 36 months, virtually xxx% of the patients reported some grade of hurting or discomfort and close to 6% of all patients reported inguinal hurting of such intensity that information technology disturbed their concentration in activities of daily life during the week preceding follow-up. By contrast, the six-year cumulative incidence of reoperation for recurrence was reported to be 4.5%.4 Furthermore, this pain caused social inability, interfering with such activities as walking, standing, and sitting in 11.3% to 14.two% of the surgically treated patients. The prevalence of long-term pain in this Swedish patient population conforms with the data reported by Bay-Nielsen and Poobalan3,viii but differs substantially from the experience of Condonix who institute that chronic pain occurred in less than 1%.
Of the variables that were independently associated with an increased run a risk of residual pain, ie, historic period, pain level before the operation, techniques involving anterior approach, and postoperative complications, only the operative technique and complications tin can potentially be controlled by the surgeon. Postoperative complications were establish to be linked to an increased risk for long-term pain in our written report. Others take not plant this link.10 In nearly studies, all the same,iii,8,11–15 complications do not seem to be evaluated at all in respect to balance pain. Our results indicate that postoperative complications may serve as an important intermediary variable,16 useful in systematic improvement systems aimed to decrease the risk for long-term postherniorrhaphy pain. Nevertheless, it must exist emphasized that the reported associations in this observational study do not necessarily represent causal relationships. Although nobody would dispute the desirability of reducing postoperative complications, data from sufficiently big randomized clinical trials are needed to prove that such efforts would also reduce the risk of long-term pain.
Operations by posterior approach (ie, laparoscopic and open posterior operations) take, in or study, shown to cause less pain than operations by groin incision. Our study did non have sufficient power to observe clinically important advantages of specific repair methods. Hence, differences might well exist. When combined into one category, surgical techniques not involving dissection of the groin were associated with a lower prevalence of residual pain after 24 to 36 months, compared with techniques requiring groin dissection. In view of the advertisement hoc character of this analysis, however, cautious interpretation is recommended. The results from recent randomized clinical trials comparing laparoscopic TEP or TAPP repair with open up tension free mesh repair are conflicting. Some trials resulted in a lower prevalence of postoperative pain in the laparoscopic group,12,thirteen,17 whereas others showed no divergence between the treatment artillery.11,14 Our finding, if true, should further be weighed against a possibly increased risk of recurrence with such techniques, as indicated in some studies.11,18
In our report, a loftier level of preoperative pain indicated an increased risk of long-term hurting, as reported also by Poobalan et al8 and Courtney et al.xv This might suggest that the hernia illness was already complicated prior to surgery in some patients; stretching, entrapment, and/or inflammation of local nerves are conceivable mechanisms, but psychologic susceptibility or increased pain sensitivity may also play a role. Moreover, the pain prior to the operation may also have originated from other weather than the hernia, and will and then persist after the functioning. A third possibility is that interindividual variations in the manner of communicating subjective feelings may have affected the observed relationship. A general inclination to report pain and other feelings in an exaggerated manner volition near likely persist both earlier and after the functioning and so will a propensity for beingness stoical. However, a cautious interpretation of these results is needed since the reply to the question of preoperative pain is the patient's recollection of the pain level. The complexity of inguinal pain is underlined by the fact that a substantial proportion of patients as well reported hurting from the nontreated contralateral groin. Randomized intervention studies are required to answer the question whether special preoperative investigations and/or tailored management, for example especially adapted analgesia and anesthesia or particularly atraumatic surgical techniques, may diminish the risk of long-term pain among patients with atypically high preoperative pain levels.
Strengths of our study include the population-based approach and the large sample size, albeit too modest for precise estimates in relation to factors such as operative technique. The prevalence of residual pain afterward hernia surgery estimated in this study is considered to mirror population-based results in Sweden, since infirmary-based health care, in exercise, is population-based and referable merely to mutually sectional hospital catchment areas. An important drawback is that we did non include patients who underwent further inguinal surgery during the 24- to 36-calendar month follow-up period. According to the annals, the proportion of the year 2000 cohort that underwent reoperation during our follow-up flow was 1.5%. Some of these reoperations might have been prompted by inguinal pain with or without noticeable hernia recurrence, which could pb to an underestimation of the prevalence of astringent postoperative pain. Another limitation is the lack of clinical evaluation of the patients who reported residual hurting. Although the questionnaire contained questions that were designed to capture obvious recurrences, some of the patients with residual hurting may still accept had a recurrent hernia.
Hernia surgery has hitherto been focused on attempts to reduce the hazard of recurrences, simply prevention of long-term pain may crave other approaches. To a certain extent, all the same, efforts aimed at reducing the recurrence rate are likely to coincide with those required to avoid rest pain. Consistent with this assumption is the fact that postoperative complications are a major risk factor for both recurrencenineteen and for long-term hurting. Although unproven in controlled trials, a meticulous technique in the dissection probably will decrease the risk of recurrence equally well as of pain. When considering other aspects of surgery, such as choice of repair, the hazard of long-term pain may take to exist weighed against the risk of recurrence. Furthermore, careful steps to control pain amidst younger patients and patients with a loftier level of preoperative pain are of import potential fields of improvement and enquiry. One obvious step that is necessary to make improvement possible regarding the endpoint long-term pain is to include evaluation of pain afterwards some years in quality assurance systems for hernia surgery.
Footnotes
Supported by the National Board of Health and Welfare (Sweden).
Reprints: Ulf Fränneby, MD, Department of Surgery, Södersjukhuset, SE-118 83 Stockholm, Sweden. East-mail: es.tesuhkujsredos@ybennarf.influenza.
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Is It Normal To Have Pain 8 Weeks After Herena Repair,
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