Turkiye Klinikleri Journal of Anesthesiology Reanimation

.: ORIGINAL RESEARCH
Abdominal Cerrahi Sonrası Kronik Ağrı Sendromlu Hastaların Retrospektif Değerlendirilmesi: 3 Yıllık Deneyimimiz
Retrospective Evaluation of Patients with Chronic Pain Syndrome After Abdominal Surgery: Our 3 Years Experience
Dostali ALİYEVa, Süheyla KARADAĞ ERKOÇb, Keziban Sanem ÇAKAR TURHANb, Fatma Feyhan ÖKTENb
aAnkara Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Renimasyon ABD, Algoloji BD, Ankara, TÜRKİYE
bAnkara Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Renimasyon ABD, Ankara, TÜRKİYE
Turkiye Klinikleri J Anest Reanim. 2021;19(1):17-25
doi: 10.5336/anesthe.2021-82607
Article Language: TR
Full Text
ÖZET
 Amaç: Kronik postoperatif ağrı (KPA) hayat kalitesini olumsuz etkileyen, iş gücü kaybı ile sağlık sistemlerine büyük bir yük getiren, yönetimi zor ve multimodal yaklaşım gerektiren önemli bir problemdir. Preoperatif ağrı, operasyon tipi, postoperatif akut ağrı ve psikososyal etkenler KPA için risk faktörleri olarak tanımlanmıştır. Bu çalışmada, hastanemizde abdominal cerrahi sonrası KPA ile algoloji servisine başvuran hastalar, retrospektif olarak incelenip risk faktörleri ortaya konmaya çalışılmıştır. Gereç ve Yöntemler: Üç yıl içinde 1.250 abdominal cerrahi geçirmiş hasta arasından, KPA nedeni ile algoloji kliniğimize baş vurmuş 50 hasta retrospektif olarak incelendi. KPA gelişmesinde etkisi olan risk faktörlerini belirlenmeye çalışıldı. Bulgular: Çalışma hastalarının %70'de (35 hasta) her şeyi felaketleştirme yani 'catastrophizing' hasta yapısı, anksiyete ve depresyon bulgularının mevcut olduğu görüldü (p0,05). Sonuç: Abdominal cerrahi sonrası KPA gelişmesinde; hastanın psikososyal yapısı, geçirilmiş ameliyat sayısı, yaşam tarzı önemli risk faktörleridir.

Anahtar Kelimeler: Kronik ağrı; laparotomi; tekrarlayan cerrahi; her şeyi felaketleştirme; anksiyete
ABSTRACT
 Objective: Chronic postoperative pain is a condition that negatively affects the quality of life, puts a huge burden on health systems with loss of work force, is difficult to treat and requires a multimodal approach. Preoperative pain, type of operation and anesthetic approach, postoperative acute pain and psychosocial factors have been identified as risk factors for chronic postoperative pain. In this study, patients who applied to the algology service with chronic postoperative pain after abdominal surgery in our hospital were retrospectively analyzed and the risk factors were tried to be revealed. Material and Methods: Among 1,250 patients who had undergone abdominal surgery in 3 years, 50 patients who applied to our algology clinic due to chronic postoperative pain were retrospectively analyzed. It was tried to determine the risk factors affecting the development of chronic postoperative pain. Results: We found that 70% of the study patients (35 patients) had catastrophizing symptoms, anxiety and depression (p0.05). Conclusion: Psychosocial structure of the patient, number of previous surgeries and lifestyle are important risk factors in the development of chronic postoperative pain after abdominal surgery.

Keywords: Chronic pain; laparotomy; reoperation; catastrophization; anxiety
REFERENCES:
  1. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618-25.[Crossref] [PubMed] 
  2. Wylde V, Dennis J, Beswick AD, Bruce J, Eccleston C, Howells N, et al. Systematic review of management of chronic pain after surgery. Br J Surg. 2017;104(10):1293-1306.[Crossref] [PubMed] [PMC] 
  3. Martucci KT, Mackey SC. Neuroimaging of pain: human evidence and clinical relevance of central nervous system processes and modulation. Anesthesiology. 2018;128(6):1241-54.[Crossref] [PubMed] [PMC] 
  4. Yang S, Chang MC. Chronic Pain: Structural and Functional Changes in Brain Structures and Associated Negative Affective States. Int J Mol Sci. 2019;20(13):3130.[Crossref] [PubMed] [PMC] 
  5. Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12(1):50-5.[Crossref] [PubMed] 
  6. Callesen T, Bech K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg. 1999;86(12):1528-31.[Crossref] [PubMed] 
  7. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl. 1986;3:S1-226.[PubMed] 
  8. Vissers MM, Bussmann JB, Verhaar JA, Busschbach JJ, Bierma-Zeinstra SM, Reijman M. Psychological factors affecting the outcome of total hip and knee arthroplasty: a systematic review. Semin Arthritis Rheum. 2012;41(4):576-88.[Crossref] [PubMed] 
  9. Pinto PR, McIntyre T, Ferrero R, Almeida A, Araújo-Soares V. Risk factors for moderate and severe persistent pain in patients undergoing total knee and hip arthroplasty: A prospective predictive study. PLoS One. 2013;8(9):e73917.[Crossref] [PubMed] [PMC] 
  10. Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017;10:2287-98.[Crossref] [PubMed] [PMC] 
  11. Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The role of psychosocial processes in the development and maintenance of chronic pain. J Pain. 2016;17(9Suppl):T70-92.[Crossref] [PubMed] [PMC] 
  12. Kuusniemi K, Pöyhiä R. Present-day challenges and future solutions in postoperative pain management: results from PainForum 2014. J Pain Res. 2016;9:25-36.[Crossref] [PubMed] [PMC] 
  13. Yang MMH, Hartley RL, Leung AA, Ronksley PE, Jetté N, Casha S, et al. Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis. BMJ Open. 2019;9(4):e025091.[Crossref] [PubMed] [PMC] 
  14. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology. 2000;93(4):1123-33.[Crossref] [PubMed] 
  15. Crombie IK, Davies HT, Macrae WA. Cut and thrust: antecedent surgery and trauma among patients attending a chronic pain clinic. Pain. 1998;76(1-2):167-71.[Crossref] [PubMed] 
  16. Correll D. Chronic postoperative pain: recent findings in understanding and management. F1000Res. 2017;6:1054.[Crossref] [PubMed] [PMC] 
  17. Lewis GN, Rice DA, McNair PJ, Kluger M. Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. Br J Anaesth. 2015;114(4):551-61.[Crossref] [PubMed] 
  18. Gupta A, Gandhi K, Viscusi ER. Persistent postsurgical pain after abdominal surgery. Techniques in Regional Anesthesia and Pain Management. 2011:15(3);140-6.[Crossref] 
  19. Strik C, van den Beukel B, van Rijckevorsel D, Stommel MWJ, Ten Broek RPG, van Goor H. Risk of pain and gastrointestinal complaints at 6 months after elective abdominal surgery. J Pain. 2019;20(1):38-46.[Crossref] [PubMed] 
  20. Werner MU, Kongsgaard UE. I. Defining persistent post-surgical pain: is an update required? Br J Anaesth. 2014;113(1):1-4.[Crossref] [PubMed] 
  21. Sullivan MJL, Bishop SB, Jayne P. The pain catastrophizing scale: development and validation. Psychological Assessment. 1995;7(4):524-32.[Crossref] 
  22. Robert S, Nicholas M. Chronic Pain: The peri-operative management of chronic pain patients and chronic pain after abdominal surgery. Anton K, Michael JPS eds. Analgesia in Major Abdominal Surgery. 1st ed. Cham, Switzerland: Springer International Publishing AG; 2018. p. 249-51.[Crossref] 
  23. Thomazeau J, Rouquette A, Martinez V, Rabuel C, Prince N, Laplanche JL, et al. Predictive factors of chronic post-surgical pain at 6 months following knee replacement: influence of postoperative pain trajectory and genetics. Pain Physician. 2016;19(5):E729-41.[Crossref] [PubMed] 
  24. Wylde V, Sayers A, Lenguerrand E, Gooberman-Hill R, Pyke M, Beswick AD, et al. Preoperative widespread pain sensitization and chronic pain after hip and knee replacement: a cohort analysis. Pain. 2015;156(1):47-54. Erratum in: Pain. 2015;156(12):2636-7.[Crossref] [PubMed] [PMC] 
  25. Joris JL, Georges MJ, Medjahed K, Ledoux D, Damilot G, Ramquet CC, et al. Prevalence, characteristics and risk factors of chronic postsurgical pain after laparoscopic colorectal surgery: Retrospective analysis. Eur J Anaesthesiol. 2015;32(10):712-7.[Crossref] [PubMed] 
  26. Holtzman S, Clarke HA, McCluskey SA, Turcotte K, Grant D, Katz J. Acute and chronic postsurgical pain after living liver donation: Incidence and predictors. Liver Transpl. 2014;20(11):1336-46.[Crossref] [PubMed] 
  27. Guimarães-Pereira L, Farinha F, Azevedo L, Abelha F, Castro-Lopes J. Persistent postoperative pain after cardiac surgery: Incidence, characterization, associated factors and its impact in quality of life. Eur J Pain. 2016;20(9):1433-42.[Crossref] [PubMed] 
  28. Bayman EO, Parekh KR, Keech J, Larson N, Vander Weg M, Brennan TJ. Preoperative Patient Expectations of Postoperative Pain Are Associated with Moderate to Severe Acute Pain After VATS. Pain Med. 2019;20(3):543-54.[Crossref] [PubMed] [PMC] 
  29. Aasvang EK, Gmaehle E, Hansen JB, Gmaehle B, Forman JL, Schwarz J, et al. Predictive risk factors for persistent postherniotomy pain. Anesthesiology. 2010;112(4):957-69.[Crossref] [PubMed] 
  30. Lange JF, Meyer VM, Voropai DA, Keus E, Wijsmuller AR, Ploeg RJ, et al. The role of surgical expertise with regard to chronic postoperative inguinal pain (CPIP) after Lichtenstein correction of inguinal hernia: a systematic review. Hernia. 2016;20(3):349-56.[Crossref] [PubMed] [PMC] 
  31. Goesling J, Moser SE, Zaidi B, Hassett AL, Hilliard P, Hallstrom B, et al. Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain. 2016;157(6):1259-65.[Crossref] [PubMed] [PMC] 
  32. Malafoglia V, Celi M, Muscoli C, Ilari S, Lauro F, Giancotti LA, et al. Lymphocyte opioid receptors as innovative biomarkers of osteoarthritic pain, for the assessment and risk management of opioid tailored therapy, before hip surgery, to prevent chronic pain and opioid tolerance/addiction development: OpMarkArt (Opioids-Markers-Arthroprosthesis) study protocol for a randomized controlled trial. Trials. 2017;18(1):605.[Crossref] [PubMed] [PMC] 
  33. Hinrichs-Rocker A, Schulz K, Järvinen I, Lefering R, Simanski C, Neugebauer EA. Psychosocial predictors and correlates for chronic post-surgical pain (CPSP) - a systematic review. Eur J Pain. 2009 ;13(7):719-30.[Crossref] [PubMed] 
  34. Kolesnikov Y, Gabovits B, Levin A, Veske A, Qin L, Dai F, et al. Chronic pain after lower abdominal surgery: do catechol-O-methyl transferase/opioid receptor μ-1 polymorphisms contribute? Mol Pain. 2013;9:19.[Crossref] [PubMed] [PMC] 
  35. Dimova V, Lötsch J, Hühne K, Winterpacht A, Heesen M, Parthum A, et al. Association of genetic and psychological factors with persistent pain after cosmetic thoracic surgery. J Pain Res. 2015;8:829-44.[Crossref] [PubMed] [PMC] 

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