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Introduction: The interference of biological, social, and psychological factors of the patient, collectively known as the biopsychosocial perspective, plays an important role in the chronification of postsurgical pain. The aim of this pilot study was to detect whether patients suffering from chronic pain without a relationship to a recent operation (CP) differ from chronic pain patients whose pain exists since a recent operation and is related with it (CPSP) in these factors., Materials and Methods: A step-by-step analysis of patients with chronic pain was conducted via a questionnaire of 36 questions in which mental state, pain, fear, and depression [Hospital Anxiety and Depression Scale - Deutsche Version (HADS-D), Chronic Pain Grade Questionnaire (CPGQ, von Korff), SF-12, McGill Pain Questionnaire (sensoric/affective)] were surveyed., Statistical Analysis: Fisher's exact test for counts, U test for continuous variables; group comparisons with: χ(2) test; p < 0.05 was considered significant., Results: On average 29 months postoperatively (24-35 ± 3.5 months), 113 chronic pain patients were analyzed. A group comparison between the CPSP group (n = 73 with chronic postsurgical pain) and the group CP (n = 29 with chronic pain) was conducted. Both groups showed highly significant reductions of SF-12 data compared to a German normal collective (p < 0.001), but normal results regarding depression in the HADS-D and a moderately limiting, highly pain-related limitation in the CPGQ (von Korff III). No differences in the sensoric and affective parameters of the McGill Pain Questionnaire were found. Compared with the CPSP group, the CP group demonstrated higher pain intensities (p = 0.022)., Conclusion: Regarding these results critically, there were no group differences concerning psychological and social patient factors in chronic pain patients with or without postsurgical pain.

Sufficient acute pain therapy has been scientifically proven to be one of the therapeutic pillars for rapid patient convalescence, a low rate of pain chronification, and a high grade of patient satisfaction. This includes not only systemic pharmacological pain therapy, but also nonpharmaceutical measures, e.g., physical, psychological, locoregional, and adequate patient information. This requires a specific infrastructure, exact clinical control mechanisms, and fundamental knowledge about pain avoidance. The surgeon can responsibly contribute to this. The goal of the following article is to demonstrate and deepen this knowledge and to describe the newest scientific developments.

Background: Open inguinal hernia repair is associated with moderate postoperative pain, but optimal analgesia remains controversial. The aim of this systematic review was to evaluate the available literature on the management of pain after open hernia surgery., Methods: Randomized studies, in English, published between January 1966 and March 2009, assessing analgesic and anaesthetic interventions in adult open hernia surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. In addition to published evidence, clinical practice was taken into account to ensure that the recommendations had clinical validity., Results: Of the 334 randomized studies identified, 79 were included. Quantitative analysis suggested that regional anaesthesia was superior to general anaesthesia for reducing postoperative pain. Spinal anaesthesia was associated with a higher incidence of urinary retention and increased time to home-readiness compared with regional anaesthesia., Conclusion: Field block with, or without wound infiltration, either as a sole anaesthetic/analgesic technique or as an adjunct to general anaesthesia, is recommended to reduce postoperative pain. Continuous local anaesthetic infusion of a surgical wound provides a longer duration of analgesia. Conventional non-steroidal anti-inflammatory drugs or cyclo-oxygenase 2-selective inhibitors in combination with paracetamol, administered in time to provide sufficient analgesia in the early recovery phase, are optimal. In addition, weak opioids are recommended for moderate pain, and strong opioids for severe pain, on request., (Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Aim: Demonstration of improved postoperative pain management by implementation of the S3 guidelines on treatment of acute perioperative and posttraumatic pain, by the integrated quality management concept "quality management acute pain" of the TÜV Rheinland or by participation in the benchmark project "Quality improvement in postoperative pain management" (QUIPS)., Methods: A prospective controlled study (pre-post design) was carried out in hospitals with various levels of care comparing three hospital groups (n = 17/7/3, respectively). Group 1: participation in the QUIPS project (intraclinic and interclinic comparison of outcome data of postoperative pain treatment), group 2: participation in the quality management acute pain program (certified by TÜV Rheinland), group 3: control group with no involvement in either of the two concepts. In all three groups, an anonymous data collection was performed consisting of patient-reported pain intensity, side effects, pain disability and patient satisfaction. Pain therapy intervention was carried out only in group 2 by an integrated quality management concept (certification project: Quality management acute pain) with a package of measures to improve structure, process and outcome quality., Results: The TÜV Rheinland certified clinics (group 2) showed a significant improvement in the pre-post comparison (before versus after certification) in the areas maximum pain (from visual analogue scale VAS 4.6 to 3.7), stress pain (5.3 to 3.9), pain-related impairment (proportion of patients with pain-linked decreased mobility and movement 26% to 16.1%, coughing and breathing 23.1% to 14.3%) and patient satisfaction (from 13.2 to 13.7; scale 0 completely unsatisfied, 15 very satisfied). The clinics with participation in QUIPS for 2 years also showed a significant improvement in stress pain (numeric rating scale NRS for pain 4.5 to 4.2), pain-linked-limitation of coughing and breathing (28% to 23.6%), and patient satisfaction (from 11.9 to 12.4). There were no differences in postoperative nausea and vomiting between any of the groups., Conclusions: The main objective of the certification concept quality management acute pain as a tool for the successful implementation of the S3 guidelines on treatment of acute perioperative and posttraumatic pain, led to a significant improvement in patient outcome. Participation in QUIPS is an ideal supplement to TÜV Rheinland certification and can be recommended as a benchmarking tool to evaluate outcome.

Background: Haemorrhoidectomy is associated with intense postoperative pain, but optimal evidence-based pain therapy has not been described. The aim of this systematic review was to evaluate the available literature on the management of pain after haemorrhoidal surgery., Methods: Randomized studies published in the English language from 1966 to June 2006, assessing analgesic and anaesthetic interventions in adult haemorrhoidal surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases., Results: Of the 207 randomized studies identified, 106 met the inclusion criteria, with mixed methodological quality. Of these, 41 studies evaluating surgical and alternative interventions were excluded. Quantitative analyses were not performed, as there were limited numbers of trials with a sufficiently homogeneous design., Conclusion: Local anaesthetic infiltration, either as a sole technique or as an adjunct to general or regional anaesthesia, and combinations of analgesics (non-steroidal anti-inflammatory drugs, paracetamol and opiates) are recommended. If appropriate, a stapled operation may be preferable., (Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://www.postoppain.org). Evidence-based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors, plus intravenous strong opioids (high-intensity pain) or weak opioids (moderate- to low-intensity pain).

Introduction: Relief of postoperative pain is a major topic of public health and has been repeatedly shown to be inadequate., Study Design: A questionnaire survey performed in seven European countries (postoperative analgesic therapy observational survey) in 746 health structures--which perform more than 80% of the total number of surgical procedures of each country--has demonstrated significant improvement when compared with previous surveys, particularly regarding increased use of multimodal analgesia and regular administration of analgesic drugs. The present study describes specific results for the 178 French health care institutions surveyed and 345 questionnaires collected. Preoperative patient information is given on a regular basis for 84% of respondents., Results: Multimodal analgesia is used after major surgery in 87% of cases and prescribed on a regular basis for 84% of respondents. Written protocols are available in 36% of responding institutions. Pain scores are measured several times a day in 65% of institutions. An acute pain service (or any other structure with a similar aim) is found in 52% of institutions. Regular on-site training courses on pain control are delivered to 30% of anaesthesiologists, to 6% of surgeons, to 57% of recovery-room nurses and to 63% of ward nurses. Overall, the study suggests an improvement of current practices but also highlights remaining insufficiencies., Conclusion: Important efforts remain to be done, particularly in the field of initial and continuous education of all healthcare categories as this is believed to be the only real way to obtain long-term results.

Background: Many patients still suffer severe acute pain in the postoperative period. Although guidelines for treating acute pain are widely published and promoted, most do not consider procedure-specific differences in pain experienced or in techniques that may be most effective and appropriate for different surgical settings. The procedure-specific postoperative pain management (PROSPECT) Working Group provides procedure-specific recommendations for postoperative pain management together with supporting evidence from systematic literature reviews and related procedures at http://www.postoppain.org, Methods: The methodology for PROSPECT reviews was developed and refined by discussion of the Working Group, and it adapts existing methods for formulation of consensus recommendations to the specific requirements of PROSPECT., Results: To formulate PROSPECT recommendations, we use a methodology that takes into account study quality and source and level of evidence, and we use recognized methods for achieving group consensus, thus reducing potential bias. The new methodology is first applied in full for the 2006 update of the PROSPECT review of postoperative pain management for laparoscopic cholecystectomy., Conclusions: Transparency in PROSPECT processes allows the users to be fully aware of any limitations of the evidence and recommendations, thereby allowing for appropriate decisions in their own practice setting.

Background: Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted., Methods: A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors., Results: Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia., Conclusions: A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.