Chronic pain after breast cancer treatment is a major clinical problem, affecting 25 to 60% of patients. Development of chronic pain after breast cancer treatment, as well as other surgical ...procedures, involves a complex pathophysiology that involves pre-, intra- and post-operative factors. This review is a systematic analysis on methodology and evidence in research into persistent pain after breast cancer treatment during the period 1995 to 2010, in order to clarify the significance and relative role of potential risk factors. Literature was identified by a search in PubMed and OVID, as well as by obtaining relevant studies from a systematic review of reference lists. Sixty papers were identified, most of these being retrospective or questionnaires. Only 2 studies included quantitative sensory testing and only 26 studies were prospective. Furthermore, about a third of the studies did not apply modern principles of surgical and adjuvant therapy. In summary, the data show inconsistencies in definition of chronic pain and treatment groups, as well as in the collection of pre- intra- and post-operative data, precluding conclusions with regard to pathophysiologic mechanisms as well as rational strategies for prevention and treatment. However, nerve damage and radiotherapy appear to be significant risk factors for chronic pain. A proposal for the design of future prospective studies is presented.
A comprehensive and systematic approach to research in chronic pain after breast cancer treatment is necessary in order to understand the pathophysiology and thus develop strategies for prevention and treatment.
Enhanced recovery after surgery (ERAS) programmes are increasingly becoming standard of care for several surgical procedures. However, compliance with ERAS protocols including pain management ...protocols remains poor. The PROSPECT (PROcedure-SPEcific Postoperative Pain ManagemenT) collaboration provides evidence-based, procedure-specific pain management recommendations presented as preoperative, intraoperative and postoperative interventions as well as surgical interventions that are easy to access, transparent and relevant to clinicians. This approach should facilitate incorporation of pain management recommendations in an ERAS protocol and improve compliance with the protocols. This article presents an improved approach to developing pain management guidelines as well as a pragmatic approach to procedure-specific perioperative pain management that could be incorporated in an ERAS pathway.
Major surgery, including total hip arthroplasty (THA) and total knee arthroplasty (TKA), is followed by a convalescence period, during which the loss of muscle strength and function is considerable, ...especially early after surgery. In recent years, a combination of unimodal evidence-based perioperative care components has been demonstrated to enhance recovery, with decreased need for hospitalization, convalescence, and risk of medical complications after major surgery-the fast-track methodology or enhanced recovery programs. It is the nature of this methodology to systematically and scientifically optimize all perioperative care components, with the overall goal of enhancing recovery. This is also the case for the care component "physiotherapy exercise" after THA and TKA. The 2 latest meta-analyses on the effectiveness of physiotherapy exercise after THA and TKA generally conclude that physiotherapy exercise after THA and TKA either does not work or is not very effective. The reason for this may be that the "pill" of physiotherapy exercise typically offered after THA and TKA does not contain the right active ingredients (too little intensity) or is offered at the wrong time (too late after surgery). We propose changing the focus to earlier initiated and more intensive physiotherapy exercise after THA and TKA (fast-track physiotherapy exercise), to reduce the early loss of muscle strength and function after surgery. Ideally, the physiotherapy exercise interventions after THA and TKA should be simple, using few and well-chosen exercises that are described in detail, adhering to basic exercise physiology principles, if possible.
Background and purpose - The number of patients who are suitable for outpatient total hip and knee arthroplasty (THA and TKA) in an unselected patient population remains unknown. The purpose of this ...prospective 2-center study was to identify the number of patients suitable for outpatient THA and TKA in an unselected patient population, to investigate the proportion of patients who were discharged on the day of surgery (DOS), and to identify reasons for not being discharged on the DOS.
Patients and methods - All consecutive, unselected patients who were referred to 2 participating centers and who were scheduled for primary THA and TKA were screened for eligibility for outpatient surgery with discharge to home on DOS. If patients did not fulfill the discharge criteria, the reasons preventing discharge were noted. Odds factors with relative risk intervals for not being discharged on DOS were identified while adjusting for age, sex, ASA score, BMI and distance to home.
Results - Of the 557 patients who were referred to the participating surgeons during the study period, 54% were potentially eligible for outpatient surgery. Actual DOS discharge occurred in 13-15% of the 557 patients. Female sex and surgery late in the day increased the odds of not being discharged on the DOS.
Interpretation - This study shows that even in unselected THA and TKA patients, same-day discharge is feasible in about 15% of patients. Future studies should evaluate safety aspects and economic benefits.
Previous studies have reported that 15% to 25% of patients treated for breast cancer experience long-term moderate-to-severe pain in the area of surgery, potentially lasting for several years. Few ...prospective studies have included all potential risk factors for the development of persistent pain after breast cancer surgery (PPBCS). The aim of this prospective cohort study was to comprehensively identify factors predicting PPBCS. Patients scheduled for primary breast cancer surgery were recruited. Assessments were conducted preoperatively, the first 3 days postoperatively, and 1 week, 6 months, and 1 year after surgery. A comprehensive validated questionnaire was used. Handling of the intercostobrachial nerve was registered by the surgeon. Factors known by the first 3 weeks after surgery were modeled in ordinal logistic regression analyses. Five hundred thirty-seven patients with baseline data were included, and 475 (88%) were available for analysis at 1 year. At 1-year follow-up, the prevalence of moderate-to-severe pain at rest was 14% and during movement was 7%. Factors associated with pain at rest were age <65 years (odds ratio OR: 1.8, P = 0.02), breast conserving surgery (OR: 2.0, P = 0.006), axillary lymph node dissection with preservation of the intercostobrachial nerve (OR: 3.1, P = 0.0005), moderate-to-severe preoperative pain (OR: 5.7, P = 0.0002), acute postoperative pain (OR: 2.8, P = 0.0018), and signs of neuropathic pain at 1 week (OR: 2.1, P = 0.01). Higher preoperative diastolic blood pressure was associated with reduced risk of PPBCS (OR: 0.98 per mm Hg, P = 0.01). Both patient- and treatment-related risk factors predicted PPBCS. Identifying patients at risk may facilitate targeted intervention.
Background Health care systems provide care to increasingly complex and elderly patients. Colorectal surgery is a prime example, with high volumes of major procedures, significant morbidity, ...prolonged hospital stays, and unplanned readmissions. This situation is exacerbated by an exponential rise in costs that threatens the stability of health care systems. Enhanced recovery pathways (ERP) have been proposed as a means to reduce morbidity and improve effectiveness of care. We have reviewed the evidence supporting the implementation of ERP in clinical practice. Methods Medline, Embase, and the Cochrane library were searched for randomized, controlled trials comparing ERP with traditional care in colorectal surgery. Systematic reviews and papers on ERP based on data published in major surgical and anesthesiology journals were critically reviewed by international contributors, experienced in the development and implementation of ERP. Results A random-effect Bayesian meta-analysis was performed, including 6 randomized, controlled trials totalizing 452 patients. For patients adhering to ERP, length of stay decreased by 2.5 days (95% credible interval CrI −3.92 to −1.11), whereas 30-day morbidity was halved (relative risk, 0.52; 95% CrI, 0.36–0.73) and readmission was not increased (relative risk, 0.59; 95% CrI, 0.14–1.43) when compared with patients undergoing traditional care. Conclusion Adherence to ERP achieves a reproducible improvement in the quality of care by enabling standardization of health care processes. Thus, while accelerating recovery and safely reducing hospital stay, ERPs optimize utilization of health care resources. ERPs can and should be routinely used in care after colorectal and other major gastrointestinal procedures.
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