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Section for Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark, henrik.kehlet{at}rh.dk
To the Editor:
Fassoulaki et al. (1) recently published a study on the effect of multimodal analgesia with gabapentin and local anesthetics on acute and chronic pain after breast cancer surgery and concluded that a "multimodal analgesic regime of local anesthetics and gabapentin is the most effective in preventing chronic pain." This study is one of several from Fassoulaki’s group studying between 20 and 25 patients and including different types of breast cancer surgery and patients either receiving or not receiving adjuvant chemotherapy or radiotherapy. Small trials that include different types of surgery and other treatments that may contribute to chronic pain have a high risk of being inconclusive, especially if assessment of pain and incisional sensory disturbances are relatively crude. This may best be demonstrated by their previous study on the effect of EMLA cream on chronic pain and sensory loss (2) in which incidence (total) of chronic pain was 43% (10 of 23), which is comparable to the present multimodal intervention with an incidence of 45% (10 of 22) (1), and therefore does not allow any conclusion on which regimen is best.
Ideally, future studies concerning the effects of perioperative analgesia on the risk of developing a chronic pain state will include well-defined patient groups (surgical procedure and adjuvant therapy) with a sufficient number of patients and with more detailed follow-up on chronic pain, its consequences, and its relationship to neural damage.
References
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