Mesh fixation methods and chronic pain after transabdominal preperitoneal (TAPP) inguinal hernia surgery: a comparison between fibrin sealant and tacks.

INTRODUCTION: Mesh fixation techniques have been associated with pain after groin hernia surgery. The aim of this study was to compare fibrin sealant and tacks for mesh fixation in laparoscopic inguinal hernia repair regarding long-term persistent pain. METHODS: Through the Danish Hernia Database, we identified patients operated for groin hernia using the transabdominal preperitoneal laparoscopic technique (TAPP) from 2009 to 2012 with fibrin sealant for mesh fixation. These were matched in a ratio of 1:2 with patients operated with TAPP using tacks. All patients were sent a validated questionnaire (the inguinal pain questionnaire) between March 2013 and June 2014. The primary outcome was pain at follow-up. RESULTS: A total of 1421 patients (84% males) answered the questionnaire (34% fibrin sealant, 66% tacks). The median follow-up was 35 months (range 12-62). Preoperative pain was associated with postoperative pain (p < 0.005), which was confirmed by multivariate analysis (OR 1.57 (CI 95% 1.40-1.77)). Furthermore, male gender was protective against postoperative pain (OR 0.47 (CI 95% 0.29-0.74)). A total of 18% in the fibrin sealant group and 20% in the tacks group reported pain during the past week at follow-up, and 6 and 7% reported pain not possible to ignore (p = 0.44). No difference was found between the fixation methods regarding getting up from a chair, sitting, or standing for more than 30 min, walking up stairs, driving a car, doing exercise, or the need for postoperative analgesics or postoperative sick leave (all p > 0.20). CONCLUSION: Mesh fixation technique did not affect long-term persistent pain. A large number of patients reported persistent pain regardless of mesh fixation technique, which emphasizes the need for preoperative information. Preoperative pain was a risk factor for persistent pain, whereas male gender was protective.

Association between reduced physical performance measures and short-term consequences after major emergency abdominal surgery: a prospective cohort study.

BACKGROUND: Major emergency abdominal surgery is associated with high morbidity with outcomes worse than for similar elective surgery, including complicated physical recovery, increased need for rehabilitation, and prolonged hospitalisation. PURPOSE: To investigate whether low physical performance test scores were associated with an increased risk of postoperative complications, and, furthermore, to investigate the feasibility of postoperative performance tests in patients undergoing major emergency abdominal surgery. We hypothesize that patients with low performance test scores suffer more postoperative complications. METHODS: The study is a prospective observational cohort study including all patients who underwent major abdominal surgery at the Department of Surgery at Zealand University Hospital between 1st March 2017 and 31st January 2019. Patients were evaluated with De Morton Mobility Index (DEMMI) score, hand grip strength, and 30-s chair-stand test. RESULTS: The study included 488 patients (median age 69, 50.6% male). Physiotherapeutic evaluation including physical performance tests with DEMMI and hand grip strength in the immediate postoperative period were feasible in up to 68% of patients undergoing major emergency abdominal surgery. The 30-s chair-stand test was less viable in this population; only 21% of the patients could complete the 30-s chair-stand test during the postoperative period. In logistic regression models low DEMMI score (< 40) and ASA classification and low hand grip strength (< 20 kg for women, < 30 kg for men were independent risk factors for the development of postoperative severe complications Clavien-Dindo (CD) grade ≥ 3. CONCLUSIONS: In patients undergoing major emergency surgery low performance test scores (DEMMI and hand grip strength), were independently associated with the development of significant postoperative complications CD ≥ 3.

Pharmacokinetics of high-dose intravenous melatonin in humans.

This crossover study investigated the pharmacokinetics and adverse effects of high-dose intravenous melatonin. Volunteers participated in 3 identical study sessions, receiving an intravenous bolus of 10 mg melatonin, 100 mg melatonin, and placebo. Blood samples were collected at baseline and 0, 60, 120, 180, 240, 300, 360, and 420 minutes after the bolus. Quantitative determination of plasma melatonin concentrations was performed using a radioimmunoassay technique. Pharmacokinetic parameters were estimated by a compartmental pharmacokinetic analysis. Adverse effects included assessments of sedation and registration of other symptoms. Sedation, evaluated as simple reaction times, was measured at baseline and 120, 180, 300, and 420 minutes after the bolus. Twelve male volunteers completed the study. Median (IQR) Cmax after the bolus injections of 10 mg and 100 mg of melatonin were 221,500.0 (185,637.5-326,175.0) pg/mL and 1,251,500.0 (864,375.0-1,770,500.0) pg/mL, respectively; mean (SD) t1/2 was 42.3 (5.6) minutes and 46.2 (6.2) minutes; mean (SD) Vd was 1.6 (0.9) L/kg and 2.0 (0.8) L/kg; mean (SD) CL was 0.0253 (0.0096) L/min · kg and 0.0300 (0.0120) L/min · kg; and median (IQR) AUC0- ∞ , 8,997,633.0 (6,071,696.2-11,602,811.9) pg · min/mL and 54,685,979.4 (36,028,638.6-105,779,612.0) pg · min/mL. High-dose intravenous melatonin did not induce sedation, evaluated as simple reaction times. No adverse effects were reported in the study.

Analgesic and antihyperalgesic effects of melatonin in a human inflammatory pain model: a randomized, double-blind, placebo-controlled, three-arm crossover study.

Antinociceptive effects of melatonin have been documented in a wide range of experimental animal models. The aim of this study was to investigate the analgesic, antihyperalgesic, and anti-inflammatory properties of melatonin using a validated burn injury (BI) model in healthy male volunteers. The design was a randomized, double-blind, placebo-controlled, three-arm crossover study. Each volunteer participated in 3 identical study sessions with intravenous administration of placebo, melatonin 10 mg, or melatonin 100 mg. Sixty minutes after bolus injection of study medication, a BI was induced by a computerized contact thermode (47.0°C, 420 seconds, 5.0 × 2.5 cm). Pain ratings during the BI and quantitative sensory testing at baseline and at 1, 2, 4, and 6 hours after the BI were performed. Quantitative sensory testing included assessments of secondary hyperalgesia areas, mechanical and thermal thresholds in the BI area, and pressure algometry. Furthermore, markers of inflammation, skin-reflectance spectrophotometry, and high-resolution ultrasonography were applied to measure skin erythema and dermal thickness in the BI area. Pain during the BI and secondary hyperalgesia areas were defined as primary outcomes. Twenty-nine volunteers were randomized and completed the study. While the BI induced large secondary hyperalgesia areas and significantly increased the markers of inflammation, no significant effects of melatonin were observed with respect to primary or secondary outcomes, compared with placebo. The administration of melatonin was not associated with any adverse effects. Melatonin did not demonstrate any analgesic, antihyperalgesic, or anti-inflammatory properties in the BI model.