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Rosendahl A, Thomsen T, Brandstrup B, Møller AM. Chronic post-surgical pain following gastrointestinal surgery: Protocol for a scoping review. Acta Anaesthesiol Scand 2024; 68:430-433. [PMID: 38096810 DOI: 10.1111/aas.14364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/28/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Chronic post-surgical pain (CPSP) significantly impacts people's lives, affecting both socioeconomic aspects as well as their rehabilitation after surgery. Yet, CPSP remains an under-researched field. The prevalence varies depending on type of surgery, which highlights the importance of surgery-specific research. This scoping review aims to investigate CPSP following gastrointestinal surgery in order to map out incidences, risk factors, and impact on quality of life (QoL) as well as identify gaps in research. METHODS The planned review will follow the Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) for Scoping Review guidelines. A search strategy will be carried out in major peer-reviewed databases and grey literature will be sought and identified. We will include original studies assessing CPSP after gastrointestinal surgery, with the exception of hernia surgery. We will chart data regarding trial characteristics, patient demographic, surgical diagnosis, risk factors, follow-up times, pain definitions and evaluations as well as impact on QoL. RESULTS We will present the included studies with a narrative summary, supplemented with descriptive statistics of the quantitative data if appropriate. CONCLUSION The planned scoping review will map out the current evidence about CPSP in adults following gastrointestinal surgery. We will identify gaps in research that can support the development of further research into CPSP after gastrointestinal surgery.
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Affiliation(s)
- Amalie Rosendahl
- Department of Anaesthesiology, Herlev and Gentofte Hospital, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
| | - Thordis Thomsen
- Department of Anaesthesiology, Herlev and Gentofte Hospital, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Brandstrup
- Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
- Department of Surgery, Holbaek Hospital, Holbaek, Denmark
| | - Ann M Møller
- Department of Anaesthesiology, Herlev and Gentofte Hospital, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
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Lv X, Zhang H, Gao J, Hou A, Ma Y, Zhou Z, Mi W, Zhang H, Liu Y. Intraoperative dexmedetomidine on postoperative pain in gastrointestinal surgery: an observational study. Int J Surg 2023; 109:887-895. [PMID: 36999795 PMCID: PMC10389438 DOI: 10.1097/js9.0000000000000360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/13/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Dexmedetomidine (DEX) is widely used for adjuvant sedation and analgesia in gastrointestinal surgeries. The authors aimed to reassess the effects of intraoperative DEX on acute pain by comprehensive analysis of the multiple dimensions of pain. MATERIALS AND METHODS In this multicentre cohort study, patients undergoing gastrointestinal surgeries were prospectively enrolled in the China Acute Postoperative Pain Study. Patients were divided into DEX and non-DEX groups based on whether DEX was used during surgery. Patient satisfaction with pain treatment (rated on a numeric rating score, 0-10) and other pain-related outcomes were evaluated using the International Pain Outcome Questionnaire on the first postoperative day. The effects of intraoperative DEX were analyzed using logistic or linear regression for dichotomous or continuous variables, respectively. Propensity score matching and subgroup analyses were performed to appraise the correlation between intraoperative DEX and postoperative pain outcomes. RESULTS Of the 1260 patients eligible for analysis, 711 (56.4%) received intraoperative DEX. Propensity score matching resulted in 415 patients in each group. Intraoperative DEX was associated with higher patient satisfaction (β: 0.556; 95% CI: 0.366-0.745), and a decrease in the percentage of time spent in severe pain (β: -0.081; 95% CI: -0.104- -0.058), anxiety (odds ratio: 0.394; 95% CI: 0.307-0.506), helplessness (odds ratio: 0.539; 95% CI: 0.411-0.707), and postoperative opioid consumption (β: -16.342; 95% CI: -27.528- -5.155). CONCLUSIONS Intraoperative DEX was associated with the prognosis of acute postoperative pain in multiple aspects in patients undergoing major gastrointestinal surgery, including increased patient satisfaction, and a reduction in the duration of severe pain, postoperative anxiety and helplessness, and postoperative opioid consumption. Future studies to determine the dose and timing of DEX administration on pain-related outcomes are warranted.
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Affiliation(s)
- Xuecai Lv
- Department of Anesthesiology, First Medical Center of Chinese PLA General Hospital
- Chinese PLA Medical School
| | - Haoyun Zhang
- Department of Anesthesiology, First Medical Center of Chinese PLA General Hospital
| | - Jie Gao
- Department of Anesthesiology, First Medical Center of Chinese PLA General Hospital
| | - Aisheng Hou
- Department of Anesthesiology, First Medical Center of Chinese PLA General Hospital
| | - Yulong Ma
- Department of Anesthesiology, First Medical Center of Chinese PLA General Hospital
| | - Zhikang Zhou
- Department of Anesthesiology, First Medical Center of Chinese PLA General Hospital
| | - Weidong Mi
- Department of Anesthesiology, First Medical Center of Chinese PLA General Hospital
- Chinese PLA Medical School
- National Clinical Research Center for Geriatric Diseases, PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing China
| | - Hong Zhang
- Department of Anesthesiology, First Medical Center of Chinese PLA General Hospital
- Chinese PLA Medical School
| | - Yanhong Liu
- Department of Anesthesiology, First Medical Center of Chinese PLA General Hospital
- Chinese PLA Medical School
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Perrodin SF, Trinh WH, Streitberger K, Di Pietro Martinelli C, Harnik MA, Holzgang M, Candinas D, Beldi G. Risk factors for chronic postsurgical pain in visceral surgery: a matched case–control analysis. Langenbecks Arch Surg 2022; 407:3771-3781. [DOI: 10.1007/s00423-022-02709-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/09/2022] [Indexed: 10/31/2022]
Abstract
Abstract
Purpose
Chronic postsurgical pain (CPSP) after abdominal visceral surgery is an underestimated long-term complication with relevant impact on health-related quality of life and socioeconomic costs. Early identification of affected patients is important. We aim to identify the incidence and risk factors for CPSP in this patient population.
Methods
Retrospective case–control matched analysis including all patients diagnosed with CPSP after visceral surgery in our institution between 2016 and 2019. One-to-two case–control matching was based on operation category (HPB, upper-GI, colorectal, transplantation, bariatric, hernia and others) and date of surgery. Potential risk factors for CPSP were identified using conditional multivariate logistic regression.
Results
Among a cohort of 3730 patients, 176 (4.7%) were diagnosed with CPSP during the study period and matched to a sample of 352 control patients. Independent risk factors for CPSP were age under 55 years (OR 2.64, CI 1.51–4.61), preexisting chronic pain of any origin (OR 3.42, CI 1.75–6.67), previous abdominal surgery (OR 1.99, CI 1.11–3.57), acute postoperative pain (OR 1.29, CI 1.16–1.44), postoperative use of non-steroidal anti-inflammatory drugs (OR 3.73, OR 1.61–8.65), opioid use on discharge (OR 3.78, CI 2.10–6.80) and length of stay over 3 days (OR 2.60, CI 1.22–5.53). Preoperative Pregabalin intake was protective (OR 0.02, CI 0.002–0.21).
Conclusion
The incidence of CPSP is high and associated with specific risk factors, some of them modifiable. Special attention should be given to sufficient treatment of preexisting chronic pain and acute postoperative pain.
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van den Beukel BAW, de Ree R, van Goor H, van der Wal SEI, Ten Broek RPG. Analgesia in patients with adhesion-related chronic abdominal and pelvic pain after surgery: a systematic review. Acta Chir Belg 2022; 122:303-311. [PMID: 33899669 DOI: 10.1080/00015458.2021.1881336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND AND OBJECTIVE Adhesions are the most common cause of chronic abdominal pain after surgery. Surgical adhesiolysis can relieve symptoms in selected patients, but many require other treatments. The aim of this study is to evaluate analgesic treatments other than abdominal surgery in chronic pain related to adhesions. DATABASE AND DATA TREATMENT A search was conducted in PubMed, Embase, and Central. Studies with patients suffering from chronic postoperative pain related to adhesions and undergoing all types' analgesic treatment were included. The primary outcome was the number of patients who improved in pain at long-term follow-up (at least 1 year). Secondary outcomes included improvement in pain at 3 months follow-up, quality of life, and physical functioning. RESULTS Searches identified 3022 citations. Four studies were included, one trial, one cohort study, and two case reports. The primary outcome was not reported. In a small trial (n = 18) pregabalin tended to have a benefit over placebo improving pain at 3 months. In the cohort study, 17 patients with chronic pelvic pain underwent a trial of sacral nerve stimulation. Eight patients who responded positively received an implanted device for continuous modulation, reporting sustainable improvement during follow-up (range: 6-36 months). One case report described improved pain at 6 months with trans-abdominis plane stimulation. The second report described improvement of physical function with manual therapy at long-term follow-up. CONCLUSIONS Low level of evidence is available regarding analgesic treatments of chronic abdominal and pelvic pain related to adhesions. The benefit of pregabalin is doubtful; nerve modulation is promising in a selected group.HighlightsAdhesions are a frequent cause of chronic abdominal and pelvic pain after surgery.Many patients are not good candidates for surgery (Adhesiolysis) or have relapses of pain.There is an important knowledge gap regarding non-surgical analgesic treatment.Analgesia in adhesion-related chronic abdominal pain after surgery.
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Affiliation(s)
- B A W van den Beukel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R de Ree
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S E I van der Wal
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R P G Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Parhiala M, Sand J, Laukkarinen J. Surgery for chronic pancreatitis in Finland is rare but seems to produce good long-term results. World J Clin Cases 2021; 9:10927-10936. [PMID: 35047603 PMCID: PMC8678871 DOI: 10.12998/wjcc.v9.i35.10927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/19/2021] [Accepted: 10/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Abdominal pain in chronic pancreatitis (CP) may require invasive interventions. Surgical procedures are rare, and little is known about the long-term results.
AIM To study the nationwide frequency of pancreatic surgery for CP in Finland, and postoperative symptoms and quality of life (QoL).
METHODS All patients in Finland with a diagnosis of CP who had undergone pancreatic surgery during 2000-2008 were selected from a national register. Only patients with CP as an indication for pancreatic surgery were included. Medical records were studied and questionnaires QLQ-C30, PAN26 and AUDIT, and symptom questionnaires were sent out.
RESULTS During the 9-year period, pancreatic surgery for CP was performed on 30 patients [77% men, median age 45 (21-62) years]. Eighty-three percent underwent endoscopic procedures before surgery. Surgery was performed a median 2 (0-10) years after the original CP diagnosis, and 17% developed postoperative complications. Primary pain relief after surgery was reported in 70% of cases. Need for strong pain medication was lower after surgery. Eight of 21 (38%) returned the questionnaires and 88% reported that surgery had reduced their pain and 63% were almost or entirely pain-free at a median 14 (10-18) years after surgery. QoL results did not differ from those in our control Finnish CP group.
CONCLUSION Surgery for CP is rare in Finland and most patients had prior endoscopic procedures. Patients who returned the questionnaires reported less pain and good QoL during the 14-year follow-up.
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Affiliation(s)
- Mikael Parhiala
- Faculty of Medicine and Health Technology, Tampere University, Tampere 33521, Finland
| | - Juhani Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere 33520, Finland
| | - Johanna Laukkarinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere 33521, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere 33520, Finland
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Opioid Analgesics and Persistent Pain After an Acute Pain Emergency Department Visit: Evidence from a Cohort of Suspected Urolithiasis Patients. J Emerg Med 2021; 61:637-648. [PMID: 34690022 DOI: 10.1016/j.jemermed.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/19/2021] [Accepted: 09/11/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Severe acute pain is still commonly treated with opioid analgesics in the United States, but this practice could prolong the duration of pain. OBJECTIVES Estimate the risk of experiencing persistent pain after opioid analgesic use after emergency department (ED) discharge among patients with suspected urolithiasis. METHODS We analyzed data collected for a longitudinal, multicenter clinical trial of ED patients with suspected urolithiasis. We constructed multilevel models to estimate the odds ratios (ORs) of reporting pain at 3, 7, 30, or 90 days after ED discharge, using multiple imputation to account for missing outcome data. We controlled for clinical, demographic, and institutional factors and used weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. RESULTS Among 2413 adult ED patients with suspected urolithiasis, 62% reported persistent pain 3 days after discharge. Participants prescribed an opioid analgesic at discharge were OR 2.51 (95% confidence interval [CI] 1.82-3.46) more likely to report persistent pain than those without a prescription. Those who reported using opioid analgesics 3 days after discharge were OR 2.24 (95% CI 1.77-2.84) more likely to report pain at day 7 than those not using opioid analgesics at day 3, and those using opioid analgesics at day 30 had OR 3.25 (95% CI 1.96-5.40) greater odds of pain at day 90. CONCLUSIONS Opioid analgesic prescription doubled the odds of persistent pain among ED patients with suspected urolithiasis. Limiting opioid analgesic prescribing at ED discharge for these patients might prevent persistent pain in addition to limiting access to these medications.
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Henn J, Lingohr P, Branchi V, Semaan A, von Websky MW, Glowka TR, Kalff JC, Manekeller S, Matthaei H. Open Abdomen Treatment in Acute Pancreatitis. Front Surg 2021; 7:588228. [PMID: 33521045 PMCID: PMC7841327 DOI: 10.3389/fsurg.2020.588228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Severe acute pancreatitis (SAP) is a heterogeneous and life-threatening disease. While recent guidelines recommend a stepwise approach starting with non-surgical techniques, emergency laparotomy remains inevitable in certain situations. Open abdomen treatment (OAT) may follow, potentially resulting in additional risks for severe morbidity. Causative factors and clinical impact of OAT in SAP are poorly understood and therefore issue of the present study. Materials and Methods: A retrospective analysis of patients admitted to the Department of General, Visceral, Thoracic and Vascular Surgery at University of Bonn suffering from acute pancreatitis (ICD K.85) between 2005 and 2020 was performed. Medical records were screened for demographic, clinical and outcome parameters. Patients who received primary fascial closure (PFC) were compared to those patients requiring OAT. SAP-specific scores were calculated, and data statistically analyzed (P = 0.05). Results: Among 430 patients included, 54 patients (13%) had to undergo emergency laparotomy for SAP. Patients were dominantly male (72%) with a median age of 51 years. Indications for surgery were infected necrosis (40%), suspected bowel perforation (7%), abdominal compartment syndrome (5%), and acute intra-abdominal hemorrhage (3%). While 22 patients (40%) had PFC within initial surgery, 33 patients (60%) required OAT including a median of 12 subsequent operations (SD: 6, range: 1-24). Compared to patients with PFC, patients in the OAT group had significantly fewer biliary SAP (P = 0.031), higher preoperative leukocyte counts (P = 0.017), higher rates of colon resections (P = 0.048), prolonged ICU stays (P = 0.0001), and higher morbidity according to Clavien-Dindo Classification (P = 0.002). Additionally, BISAP score correlated positively with the number of days spent at ICU and morbidity (P = 0.001 and P = 0.000002). Both groups had equal mortality rates. Discussion: Our data suggest that preoperative factors in surgically treated SAP may indicate the need for OAT. The procedure itself appears safe with equal hospitalization days and mortality rates compared to patients with PFC. However, OAT may significantly increase morbidity through longer ICU stays and more bowel resections. Thus, minimally invasive options should be promoted for an uncomplicated and rapid recovery in this severe disease. Emergency laparotomy will remain ultima ratio in SAP while patient selection seems to be crucial for improved clinical outcomes.
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Affiliation(s)
- Jonas Henn
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Philipp Lingohr
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Vittorio Branchi
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Alexander Semaan
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Martin W von Websky
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Tim R Glowka
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Steffen Manekeller
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Hanno Matthaei
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
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Vriesman MH, Noor N, Koppen IJ, Di Lorenzo C, de Jong JR, Benninga MA. Outcomes after enterostomies in children with and without motility disorders: A description and comparison of postoperative complications. J Pediatr Surg 2020; 55:2413-2418. [PMID: 32600839 DOI: 10.1016/j.jpedsurg.2020.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 04/28/2020] [Accepted: 05/15/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To provide an overview of complications after ileostomy or colostomy procedures in children, and to compare outcomes between patients with gastrointestinal motility disorders (i.e. functional constipation, Hirschsprung's disease, pediatric intestinal pseudo-obstruction (PIPO)) and children without motility disorders (including necrotizing enterocolitis, anorectal malformation and inflammatory bowel disease). METHODS We performed a retrospective study of children who underwent an enterostomy procedure at our institution. The number and type of complications and subsequent reoperations after ostomy formation were determined. Complications were scored using the Clavien-Dindo classification. A complication of ≥ grade III-b was considered a high-grade complication. RESULTS 129 children with an ileostomy and 61 children with a colostomy were included. Of these, 62 children (32.6%) had motility disorders; functional constipation (n=40), Hirschsprung's disease (n=18) and PIPO (n=4). The total prevalence of complications was 73.2%. Comparing the perioperative data, children with motility disorders significantly more often underwent a laparoscopic procedure (59.7% vs. 10.9%, p=0.000) and had an end stoma-configuration (37.1% vs. 14.1%, p=0.000) as compared to children without motility disorders. Children with motility problems had a higher complication rate (88.7% vs. 65.5%, OR 4.1, 95% CI 1.7-9.8, p=0.001) compared to children without motility problems, and a larger proportion of complications was classified as high-grade complications (61.8% vs. 31.0% p =0.002). CONCLUSION A high complication rate after enterostomy formation was detected. Children with gastrointestinal motility disorders had more and more severe complications as compared to children without motility disorders. LEVEL OF EVIDENCE Level III TYPE OF STUDY: Retrospective comparative study.
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Affiliation(s)
- Mana H Vriesman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Najia Noor
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ilan J Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Justin R de Jong
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Clinical adhesion score (CLAS): development of a novel clinical score for adhesion-related complications in abdominal and pelvic surgery. Surg Endosc 2020; 35:2159-2168. [PMID: 32410083 PMCID: PMC8057995 DOI: 10.1007/s00464-020-07621-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/02/2020] [Indexed: 02/07/2023]
Abstract
Background Adhesions are a major cause of long-term postsurgical complications in abdominal and pelvic surgery. Existing adhesion scores primarily measure morphological characteristics of adhesions that do not necessarily correlate with morbidity. The aim of this study was to develop a clinical adhesion score (CLAS) measuring overall clinical morbidity of adhesion-related complications in abdominal and pelvic surgery. Methods An international Delphi study was performed to identify relevant score items for adhesion-related complications, including small bowel obstruction, female infertility, chronic abdominal or pelvic pain, and difficulties at reoperation. The CLAS includes clinical outcomes, related to morbidity of adhesions, and weight factors, to correct the outcome scores for the likelihood that symptoms are truly caused by adhesions. In a pilot study, two independent researchers retrospectively scored the CLAS in 51 patients to evaluate inter-observer reliability, by calculating the Intraclass correlation coefficient. During a feasibility assessment, we evaluated whether the CLAS completely covered different clinical scenarios of adhesion-related morbidity. Results Three Delphi rounds were performed. 43 experts agreed to participate, 38(88%) completed the first round, and 32 (74%) the third round. Consensus was reached on 83.4% of items. Inter-observer reliability for the CLAS was 0.95 (95% CI 0.91–0.97). During feasibility assessment, six items were included. As a result, the CLAS includes 22 outcomes and 23 weight factors. Conclusion The CLAS represents a promising scoring system to measure and monitor the clinical morbidity of adhesion-related complications. Further studies are needed to confirm its utility in clinical practice. Electronic supplementary material The online version of this article (10.1007/s00464-020-07621-5) contains supplementary material, which is available to authorized users.
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Krielen P, Stommel MWJ, Pargmae P, Bouvy ND, Bakkum EA, Ellis H, Parker MC, Griffiths EA, van Goor H, Ten Broek RPG. Adhesion-related readmissions after open and laparoscopic surgery: a retrospective cohort study (SCAR update). Lancet 2020; 395:33-41. [PMID: 31908284 DOI: 10.1016/s0140-6736(19)32636-4] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/30/2019] [Accepted: 10/18/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Adhesions are the most common driver of long-term morbidity after abdominal surgery. Although laparoscopy can reduce adhesion formation, the effect of minimally invasive surgery on long-term adhesion-related morbidity remains unknown. We aimed to assess the impact of laparoscopy on adhesion-related readmissions in a population-based cohort. METHODS We did a retrospective cohort study of patients of any age who had abdominal or pelvic surgery done using laparoscopic or open approaches between June 1, 2009, and June 30, 2011, using validated population data from the Scottish National Health Service. All patients who had surgery were followed up until Dec 31, 2017. The primary outcome measure was the incidence of hospital readmissions directly related to adhesions in the laparoscopic and open surgery cohorts at 5 years. Readmissions were categorised as directly related to adhesions, possibly related to adhesions, and readmissions for an operation that was potentially complicated by adhesions. We did subgroup analyses of readmissions by anatomical site of surgery and used Kaplan-Meier analyses to assess differences in survival across subgroups. We used multivariable Cox-regression analysis to determine whether surgical approach was an independent and significant risk factor for adhesion-related readmissions. FINDINGS Between June 1, 2009, and June 30, 2011, 72 270 patients had an index abdominal or pelvic surgery, of whom 21 519 (29·8%) had laparoscopic index surgery and 50 751 (70·2%) had open surgery. Of the 72 270 patients who had surgery, 2527 patients (3·5%) were readmitted within 5 years of surgery for disorders directly related to adhesions, 12 687 (17·6%) for disorders possibly related to adhesions, and 9436 (13·1%) for operations potentially complicated by adhesions. Of the 21 519 patients who had laparoscopic surgery, 359 (1·7% [95% CI 1·5-1·9]) were readmitted for disorders directly related to adhesions compared with 2168 (4·3% [4·1-4·5]) of 50 751 patients in the open surgery cohort (p<0·0001). 3443 (16·0% [15·6-16·4]) of 21 519 patients in the laparoscopic surgery cohort were readmitted for disorders possibly related to adhesions compared with 9244 (18·2% [17·8-18·6]) of 50 751 patients in the open surgery cohort (p<0·005). In multivariate analyses, laparoscopy reduced the risk of directly related readmissions by 32% (hazard ratio [HR] 0·68, 95% CI 0·60-0·77), and of possibly related readmissions by 11% (HR 0·89, 0·85-0·94) compared with open surgery. Procedure type, malignancy, sex, and age were also independently associated with risk of adhesion-related readmissions. INTERPRETATION Laparoscopic surgery reduces the incidence of adhesion-related readmissions. However, the overall burden of readmissions associated with adhesions remains high. With further increases in the use of laparoscopic surgery expected in the future, the effect at the population level might become larger. Further steps remain necessary to reduce the incidence of adhesion-related postsurgical complications. FUNDING Dutch Adhesion Group and Nordic Pharma.
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Affiliation(s)
- Pepijn Krielen
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Pille Pargmae
- Department of Gynaecology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Erica A Bakkum
- Department of Gynaecology, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Harold Ellis
- Department of Anatomy, Guy's Hospital, London, UK
| | - Michael C Parker
- Darent Valley Hospital, Dartford, UK; Aarhus University Hospital, Aarhus, Denmark
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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