Significant factors influencing chronic postoperative inguinal pain: A conditional time-dependent observational cohort study

The impact of smoking on ventral and inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair.

SOURCE

A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma.

PRINCIPAL FINDINGS

Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger's test showed the absence of publication bias in the study outcomes.

CONCLUSION

This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair.

PROSPERO REGISTRATION

ID CRD42024517640.

Comparison of postoperative chronic inguinal pain between the lichtenstein and laparoscopic techniques in the treatment of inguinal hernia: a systematic review and meta-analysis

PURPOSE

Currently, inguinal hernias are highly prevalent in the Brazilian population, accounting for 75% of all abdominal wall hernias. The recommended treatment to correct them is inguinal herniorrhaphy, which can be performed through open surgery, mainly using the Lichtenstein technique, or laparoscopically, primarily through Transabdominal Preperitoneal Repair (TAPP) or Total Extraperitoneal Repair (TEP) approaches. Like any surgery, these procedures have post-operative complications, with pain being the most common and debilitating. Currently, in European and Brazilian guidelines, the open Lichtenstein and endoscopic inguinal hernia techniques are recommended as best evidence-based options for repair of a primary unilateral hernia providing the surgeon is sufficiently experienced in the specific procedure. In that matter, the surgeon should make a choice based on assessment of the benefits and risks of performing each of them, and practice shared making decision with it patient. Therefore, the objective of this review was to assess the incidence of chronic postoperative pain by comparing the aforementioned surgical approaches to evaluate which procedure causes less disability to the patient.

METHODS

The search conducted until May 2024 was performed on Medline (PubMed), Cochrane (CENTRAL), and Lilacs databases. The selection was limited to randomized clinical trials, nonrandomized clinical trials and cohort studies comparing TAPP or TEP to LC, evaluating the incidence of chronic postoperative pain published between 2017 and 2023. Evidence certainty was assessed using the GRADE Pro tool, and bias risk was evaluated with the RoB 2.0 tool and ROBINS I tool. Thirteen studies were included.  RESULTS: The meta-analysis showed a significant difference between the groups in both techniques, favoring the laparoscopic approach, which had a lower occurrence of postoperative inguinodynia with a relative risk of 0.49 (95% CI = 0.32, 0.75; I2 = 66% (P = 0.001); Z = 3.28 (P = 0.001) with low certainty of evidence.

CONCLUSION

The presence of chronic postoperative pain was lower in laparoscopic TEP/TAPP techniques when compared to the open Lichtenstein technique, meaning that the former can bring more benefits to patients who requires inguinal herniorrhaphy. Nevertheless, further randomized clinical trials are needed to optimize the analysis, minimizing the bias.

Quadratus lumborum block versus transversus abdominis plane block for inguinal hernia repair: A systematic review and meta-analysis with trial sequential analysis

INTRODUCTION

Postoperative pain management is crucial for patient recovery with Quadratus Lumborum Block (QLB) and Transversus Abdominis Plane Block (TAPB) emerging as potential techniques. We aimed to compare the analgesic efficacy of QLB and TAPB in patients undergoing inguinal hernia repair.

METHODS

We performed a systematic review of Cochrane, EMBASE, and MEDLINE databases to identify randomized controlled trials comparing QLB and TAPB in patients undergoing inguinal hernia repair. Outcomes included postoperative pain and opioid consumption. Statistical analysis was performed using RevMan 5.4. The review protocol was registered at PROSPERO (CRD42023445513).

RESULTS

We included five RCTs encompassing 255 patients. QLB was associated with a significant decrease in postoperative pain (MD -0.45; 95% CI -0.75 to -0.14; and p = 0.004; I2  = 94%). However, we found no difference in 24-h opioid consumption between QLB and TAPB groups.

CONCLUSION

QLB may offer superior pain reduction. However, its effect on opioid consumption remains unclear.

Mechanisms inherent in acute-to-chronic pain after surgery - risk, diagnostic, predictive, and prognostic factors

PURPOSE OF REVIEW

Pain is an expected consequence of a surgery, but it is far from being well controlled. One major complication of acute pain is its risk of persistency beyond healing. This so-called chronic post-surgical pain (CPSP) is defined as new or increased pain due to surgery that lasts for at least 3 months after surgery. CPSP is frequent, underlies a complex bio-psycho-social process and constitutes an important socioeconomic challenge with significant impact on patients' quality of life. Its importance has been recognized by its inclusion in the eleventh version of the ICD (International Classification of Diseases).

RECENT FINDINGS

Evidence for most pharmacological and non-pharmacological interventions preventing CPSP is inconsistent. Identification of associated patient-related factors, such as psychosocial aspects, comorbidities, surgical factors, pain trajectories, or biomarkers may allow stratification and selection of treatment options based on underlying individual mechanisms. Consequently, the identification of patients at risk and implementation of individually tailored, preventive, multimodal treatment to reduce the risk of transition from acute to chronic pain is facilitated.

SUMMARY

This review will give an update on current knowledge on mechanism-based risk, prognostic and predictive factors for CPSP in adults, and preventive and therapeutic approaches, and how to use them for patient stratification in the future.

Change in perioperative neutrophil-lymphocyte ratio as a potential predictive biomarker for chronic postsurgical pain and quality of life: an ambispective observational cohort study

Introduction

Accurate and accessible predictors of chronic postsurgical pain (CPSP) to identify high-risk postsurgical patients are prerequisite for preventive and interventional strategies. We investigated the incidence and risk factors of CPSP after abdominal surgery, with a focus on plasma immunological markers.

Materials and methods

This was a retrospective analysis of patients who underwent abdominal surgery under general anesthesia at a tertiary center between January 2021 and January 2022. The preoperative demographics, laboratory test data, and surgical factors of the participants were collected from the electronic medical record system. Postoperative pain intensity and living conditions at 1 year after discharge from the hospital were assessed via a phone survey. Univariate and multivariate analyses were used to explore independent risk factors associated with CPSP.

Results

A total of 968 patients were included, and 13.53% (n = 131 of 968) of patients reported CPSP 1 year after surgery. Patients with older age, open surgery, higher American Association of Anesthesiologists classification, patient-controlled intravenous analgesia application, longer surgery duration, higher postoperative absolute neutrophil count, and neutrophil-lymphocyte ratio (NLR), lower postoperative absolute lymphocyte count, and higher white blood cell count, were more likely to suffer from CPSP. A changed ratio of NLR (postoperative to preoperative) ≥ 5 significantly correlated with CPSP, moderate to severe pain, maximum numeric rating score since discharge from the hospital, and affected quality of life.

Discussion

The changed ratio of NLR could be used for the early identification of patients at risk for CPSP and affect the quality of life to alert the clinician to undertake further assessment.