Postoperative pain management relevant for specific surgical procedures is debated. The importance of evaluating pain with consideration given to type of surgery and the patient’s perspective has been emphasized. In this prospective cohort study, we analysed outcome data from 607 patients in the international PAIN OUT registry for assessment and comparison of postoperative pain outcome within the 24 first hours after laparoscopic and open colonic surgery. Patients from the laparoscopic group scored
Providing a high quality pain treatment is a major challenge in health care. Despite the developments in pain management, postoperative pain is still a clinical problem [
PAIN OUT started as a European commission-founded project aiming to improve clinical care of patients with postoperative pain [
In the present cohort study, registry data from patients undergoing laparoscopic and open colonic surgery were included. The registry data had been collected between February 2010 and November 2012 from one to three surgical departments in each of the following countries: France, Germany, Italy, Israel, Romania, Spain, Sweden, Switzerland, and United Kingdom. Inclusion criteria were that patients had to be 16 to 18 years old or older (consenting age varies in the different countries) and could communicate. Patients were excluded if they (I) had been transferred to another ward after surgery; (II) were not present at the ward at the time of data collection; (III) had visitors at the time of data collection; (IV) refused to participate in the study; (V) were sedated or asleep; (VI) had a cognitive dysfunction that precluded complete cooperation. Process data including pre-, intra-, and postoperative variables were collected from the medical records on postoperative day one. On the same day, patients completed an outcome questionnaire, when they were back in the ward for at least 6 hours [
The study was planned and implemented based on ethical principles commonly applied in clinical research. All respondents gave their informed consent to enrolment in the study and were guaranteed confidentiality. The study was approved by the institutional review board or ethics committee at all sites. Each patient’s oral consent and written consent were obtained before inclusion.
Within the PAIN OUT project, the multi-item International Pain Outcomes Questionnaire (IPOQ) was developed. In the IPOQ patients’ self-reported outcomes are assessed by an 11-point scale ranging from 0 to 10 (a lower score indicates less problem/difficulty). The questionnaire is presented in detail elsewhere [
A descriptive analysis was performed to assess the characteristics of the study sample. The demographic data were described by frequency distribution, mean and range, or mean and standard deviation (SD), respectively, when appropriate. To evaluate differences between the laparoscopic and open surgery groups in demographic variables, chi-square tests were used. Significant differences between the groups in patient outcome data were tested with the nonparametric Mann-Whitney
A total of 619 patients who underwent colonic surgery were identified from the PAIN OUT registry. Twelve patients (2%) were excluded because the procedure was changed from laparoscopic to open surgery. From the remaining 607 patients, 450 (74%) had undergone open surgery and 157 (26%) had undergone laparoscopic surgery. The most frequent localization of surgery was right and left hemicolectomy. Patient demographic data and intraoperative characteristics are presented in Table
Demographic data (frequencies, mean, range, SD, and chi-square test) of the participants and of intraoperative characteristics.
Open surgery | Laparoscopic surgery | Chi-square test |
|
---|---|---|---|
Sex, |
0.712 | ||
Female | 198 (44) | 71 (45) | |
Male | 251 (55) | 84 (54) | |
Unknown | 1 ( |
2 ( |
|
|
|||
Age (years), mean (SD) | 63 ( |
60 ( |
|
Age, group | 0.018 | ||
18–65, |
223 (49) | 95 (60) | |
>65, |
224 (50) | 61 (39) | |
Unknown | 3 ( |
1 ( |
|
|
|||
Type of surgery1, |
|||
Cecectomy | 43 ( |
4 ( |
|
Right hemicolectomy | 188 (31) | 42 ( |
|
Resection transverse colon | 11 ( |
18 ( |
|
Left hemicolectomy | 51 ( |
10 ( |
|
Sigmoidectomy | 101 ( |
70 ( |
|
Unspecified excision LI2 | 56 ( |
13 ( |
|
|
|||
Duration of surgery | |||
Mean (range), min | 173 (30–695) | 182 (40–600) | 0.573 |
|
|||
Anaesthesia technique | <0.01 | ||
GA, |
169 (37) | 87 (58) | |
GA + RA, |
275 (61) | 63 (42) | |
Unknown | 6 ( |
2LI = large intestine.
Patient’s self-assessments of pain management outcomes on the first postoperative day are presented in Figures
Distribution of the scores for
Distribution of the scores for pain
Distribution of the scores for pain interfering with
Distribution of the scores for
A significant difference was seen between the groups in the distribution of age and anaesthesia technique. In the laparoscopic surgery group, there was a higher frequency of patients in the age group ≤65 years (
Only one item in the IPO questionnaire showed a significant difference between laparoscopic and open surgery. The patients from the laparoscopic group scored
Frequencies, mean, SD, and significant difference for type of surgery.
Item | Open surgery | Laparoscopic surgery | Mann-Whitney |
||||
---|---|---|---|---|---|---|---|
|
M | SD |
|
M | SD |
|
|
Worst pain1 | 404 | 5.08 | 2.91 | 142 | 5.56 | 2.55 | 0.131 |
Least pain1 | 403 | 1.61 | 1.72 | 141 | 1.97 | 1.74 | 0.012 |
Pain interfering with activities in bed2 | 385 | 4.75 | 3.05 | 135 | 5.04 | 3.03 | 0.345 |
Pain interfering with activities out of bed2 | 261 |
3.93 | 3.00 | 117§ | 4.27 | 2.94 | 0.261 |
Being anxious3 | 399 | 2.23 | 2.91 | 139 | 2.55 | 2.97 | 0.207 |
Being helpless3 | 396 | 2.13 | 2.95 | 134 | 2.40 | 3.14 | 0.475 |
Being satisfied with the result of pain treatment4 | 380 | 8.29 | 2.03 | 136 | 8.04 | 2.00 | 0.076 |
The findings of this cohort study are based on data from an international pain registry. In the comparison of patient outcomes within 24 hours after laparoscopic and open colonic surgery, the laparoscopic group scored a significantly higher level of minimum pain. Although statistically significant, these values do not have much clinical importance. Apart from minimum pain, no other significant differences in patient reported outcomes were observed. Postoperative pain management relevant to specific surgical procedures is debated since the efficacy of different analgesic approaches varies between different surgical procedures [
Generally, postoperative pain constitutes an important issue for patients undergoing surgery [
During the last decade, the use of PROs has been introduced to quality registries [
A limitation is that we did not have access to data concerning the patients who were excluded. Given the large number of exclusion criteria, for example, patients who were not present at the ward, were in too much pain or too ill, and did not want to participate are not represented in the registry, thereby introducing a potential source of bias. Furthermore, the assessment of postoperative pain and pain management was performed only within the first 24 hours after the surgical intervention. Patients experience pain of varying levels during a number of days after colonic surgery [
The overall planning of postoperative care and nursing interventions should be performed out of a procedure specific perspective. Comparisons of laparoscopic and open colonic surgery have been performed in the nursing literature. Nurses working in a specialist colorectal unit perceived improved outcomes in terms of lower pain intensity among patients who had undergone laparoscopic surgery. They also perceived that it took less effort to care for the laparoscopic patients [
More frequent administration of analgesics for mild pain after laparoscopic surgery was reported in a retrospective study, suggesting that laparoscopic surgery is less painful [
According to registry, clinical data surgical technique does not influence the quality of postoperative pain management during the first postoperative day if adequate analgesia for the procedure in question is given.
The authors declare that they have no competing interests.
The PAIN OUT project was funded by the European Commission 7th Framework Programme, Call HEALTH-2007-3.1_4: Improving Clinical Decision-Making, and endorsed by the International Association for the Study of Pain.