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Department of Anesthesiology, Aretaieio Hospital, Medical School, University of Athens, Athens, Greece, afassou1{at}otenet.gr, fassoula{at}aretaieio.uoa.gr
In Response:
We agree with Dr. Kehlet (1) that future studies on chronic postoperative pain development are needed and that our statement "a multimodal analgesic regime of local anesthetics and gabapentin is the most effective in preventing chronic pain" is an exaggeration.
In response to Dr. Kehlet’s other comments: 1. In our studies (2–5), both mastectomy and tumor excision surgery were always accompanied by axillary lymph node excision. After breast surgery plus axillary lymph node excision, patients often visit the pain clinic because chronic axillary and arm pain prevent them from functioning normally in their professional and private lives. Also, group randomization should overcome any differences between mastectomy and tumor excision surgery; 2. We kept the protocols of all four studies as consistent as possible regarding patients’ age, standardized anesthetic technique, surgeons who performed the operations, etc. However, postoperative chemotherapy and radiotherapy cannot be controlled. Again, randomization and recruitment of a sufficient number of patients compensates for such discrepancies, provided that informed censoring does not occur after randomization.
Postoperative follow-up to assess chronic pain development is time-consuming and requires good patient cooperation and education during his/her stay in the hospital, carefully kept records of the pain and analgesics used at home, and contacting the patient at predetermined times. Retrospective studies are not conclusive. Multicenter trials may be influenced by the different patient cultures and different approaches to anesthetic techniques and postoperative pain among the different centers.
Randomized controlled trials (RCTs) at a single center include a limited number of patients, as each study must be completed within a reasonable period of time, under similar conditions (standardized anesthetic technique, surgeons, postoperative treatment for cancer). The limited number of RCTs investigating late postoperative pain (1–3 mo) or chronic postoperative pain (
3 mo) reflects the work required and the problems involved in long-term patient follow-up. The usual period for assessing postoperative pain is 24–48 h, although some studies limit this period to just 4 h (6).
Another important issue is when we assess chronic postoperative pain. At 3 mo postoperatively pain is often attenuated or resolved (5,7). For example, in the literature the incidence of chronic inguinal postherniorrhaphy pain varies (8–10), but the time of assessment is also variable. Dr. Kehlet proposes "a scheme for uniform assessment of chronic postherniorrhaphy pain in order to facilitate interpretation of future studies" (11). We believe this applies to all surgical procedures, particularly those in which postoperative chronic pain is common. We look forward to RCTs, as level 1 studies are the most conclusive to change or improve our clinical practice.
References
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