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Abdominal Adhesions and Pain Six Months After Elective Abdominal Surgery; a Prospective Analysis
Chema Strik*, Martijn W. Stommel, Richard P. Ten Broek, Harry Van Goor
Abdominal Surgery, Radboud University Medical Center, Nijmegen, Netherlands
Background
The incidence of chronic postoperative abdominal pain (CPAP) after surgery is estimated at 11%. Intra-abdominal adhesions are the cause of CPAP in 57% of the patients. Diagnosing adhesions as the cause of CPAP is usually done per exclusionem. Due to the mixed results of laparoscopic adhesiolysis as treatment for CPAP their causative relationship has been debated. Studies assessing CPAP after abdominal surgery showed an increased risk for female gender, age, and preoperative anxiety and depression. However, these studies lack data on preoperative health and pain status, or are limited by small patient samples. Additionally, the impact of the presence and severity of adhesions at abdominal surgery on CPAP has never been investigated.
Aim
To assess the impact of adhesions and to elucidate risk factors for the prevalence of chronic postoperative abdominal pain.
Methods
Design
Prospective cohort study, before surgery and 6 months after discharge patients were asked to complete a pain questionnaire. CPAP was defined as pain impacting social functioning or worse. Univariable and multivariable analyses were used to assess risk factors for CPAP.
Settings
A single institution
Participants
Patients participating in the LAPAD study, undergoing elective abdominal surgery
Results
518 (78%) out of 662 patients completed pre- and postoperative questionnaires. 330 (64%) patients showed to have adhesions at the time of surgery. 127 (39%) patients with adhesions had intra-abdominal pain before undergoing surgery compared to 51 (27%) patients without adhesions (p = 0.01). 6 months after discharge, 120 (36%) patients with adhesions had abdominal pain versus 64 (34%) patients without adhesions (p = 0.60). In the multivariable analysis, factors independently decreasing the risk for having CPAP were higher age (OR 0.97; p 0.001) and BMI (OR 0.93; p 0.006), lower preoperative anxiety and depression symptom score (OR 0.32; p 0.045), and usage of a median incision (OR 0.52; p 0.006) (table 1). The presence of pain longer than three months (OR 3.99; p 0.000), preoperative usage of opioid analgesia (OR 3.54; p 0.001), a higher minimal NRS value on postoperative day 2 (OR 1.23; p 0.004) and severe adhesions underneath the incision (OR 1.63; p 0.040) showed to independently increase the risk for having abdominal pain 6 months after surgery.
Conclusion
1 in 3 patients will have CPAP 6 months after elective abdominal surgery. The duration of preoperative pain, preoperative usage of opioid analgesia and the severity of acute postoperative pain and severe adhesions underneath the incision increase the risk for having CPAP 6 months after surgery. Older age and lower preoperative anxiety and depression symptom score showed to be protective for CPAP. These results can be used for improving patient counseling.
Table 1 Multivariable logistic regression analysis for having chronic postoperative abdominal pain* (CPAP)
| Patient factor | Odds Ratio | Lower limit 95% CI | Upper limit 95% CI | p value | | Age | 0.97 | 0.96 | 0.99 | 0.001 | | BMI | 0.93 | 0.89 | 0.98 | 0.004 | | Preoperative depression and anxiety symptom scale† | 0.32 | 0.11 | 0.98 | 0.045 | | Presence of pain in time; No pain | Ref. category | | | | | Presence of pain in time before surgery; pain duration shorter than 3 months | 2.69 | 1.21 | 6.00 | 0.016 | | Presence of pain in time before surgery; longer than 3 months | 3.99 | 2.48 | 6.42 | 0.000 | | Preoperative usage of opioid analgesia | 3.54 | 1.66 | 7.57 | 0.001 | | Surgical approach; median incision | 0.52 | 0.33 | 0.83 | 0.006 | | Anatomical location of surgery; Upper gastrointestinal tract | 1.85 | 0.91 | 3.77 | 0.091 | | Creation of colostomy | 0.40 | 0.15 | 1.05 | 0.064 | | Severe adhesions underneath incision‖ | 1.63 | 1.02 | 2.59 | 0.011 | | NRS pain value on postoperative day 2‡ | 1.23 | 1.07 | 1.41 | 0.004 |
*Chronic abdominal pain was defined as abdominal pain impacting social functioning or worse; Explanation special characters; †: as measured by the preoperative mental health subscale of the SF-36; ‖: Severe adhesions were defined as grade 3 and 4 adhesions as classified by the Zühlke classification; ‡: the minimal NRS (Normative Rating Scale) value reported by patients on postoperative day 2
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