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Another reason to delay. Not a good sign for progress
Here is a new paper about chronic pain. The trend in new opinions seems to be the same as it was many years ago – the data is flawed, therefore do nothing while we try to collect better data.
The first sentence in the Discussion shows that they are either very unaware of their own bias or are very aware and stating it in clear words. Overall, kind of a strange piece of work, confirming the complexity of a problem but not really offering any immediate suggestions of value. Suggesting that a problem is too undefined to make a decision is the classic way to get people to just continue on with what they’ve been doing. They can’t stop and there’s no obvious way to improve – just carry on as before. Don’t believe what you’re reading in the professional journals. Ironic.
A Critical Appraisal of the Chronic Pain Rate After Inguinal Hernia Repair
Anders Gram-Hanssen*, Stina Öberg and Jacob Rosenberghttps://www.frontierspartnerships.org/articles/10.3389/jaws.2023.10972/full
“Purpose: To critically appraise highly cited studies reporting on the rate of chronic pain after inguinal hernia repair.
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Discussion
In this review, we wanted to demonstrate the uncertainty that remains about the rate of chronic pain after inguinal hernia repair.…
Conclusion
In this review, we have explained and demonstrated that the chronic pain rates conventionally reported after inguinal hernia repair in the literature are obsolete, probably inaccurate, and likely exaggerated. This is due to uncertainties about the definition and measurement of chronic pain, other methodological shortcomings, and the fact that recent advances in inguinal hernia surgery are not reflected in the included publications. We have also highlighted the importance of solving these issues by determining consensus-based definitions and standards, and subsequently performing large, well-designed studies to establish a more accurate chronic pain rate. For this, we need prospective multicentre studies that apply clear evidence- and consensus-based definitions, use validated measurement instruments, and are reflective of current surgical practice and quality. “ -
5 Replies
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One last thing that I realized – if the authors’ conclusions are accepted, then the chronic pain portions of the European Hernia Society Guidelines are based on flawed data. The authors excluded contemporary studies, meaning that they focused on the types of studies that the EHS used to create the Guidelines.
So, rather than no-change, maybe they will invalidate the Guidelines completely. Or strip out all of the chronic pain conclusions and go back to recurrence only as the measure for recommendation.
Hard to see anything good for patient welfare resulting from what’s going on in the industry. Except the refinement of robotics methods for mesh removal.
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The Journal of Abdominal Wall Surgery is an Official Journal of the European Hernia Society. The EHS, the same group that is updating the Hernia Repair “Guidelines”.
The deeper you look the more you find the same people that were involved in the beginning. Any recommendations for change will contain an implicit conclusion that the original Guidelines were flawed. They are all stuck.
I hope that I am wrong but all signs seem to be leaning toward no change, no improvement.
https://www.frontierspartnerships.org/journals/journal-of-abdominal-wall-surgery
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Here is an example of work done to clarify the situation that the authors say they are attempting to clarify. Linked at the bottom of this post. If you take the authors’ word in the conclusion then it is useless.
Actually, each time I look back through the work I find that it is almost identical in poor quality to the work that they say is of poor quality. It’s very meta. A work of poor quality about work of poor quality. The more you look the more you see that is a study with an agenda.
Here is a selection of statements that should have caused the paper to be rejected. Actually, anyone can read the Limitations section and probably come to the same conclusion I did – this paper has no value. But it was published in a major journal.
“Limitations
This study is an informal review of 20 high-impact studies. It is not a comprehensive systematic review of the entire literature, and due to the nature of this study, it does not include more contemporary research.”“The applied search engine, Google Scholar, is an excellent source of freely available bibliometric data, however, it does provide some limitations.”
“Google Scholar only allows for access to the 1,000 most relevant search results for any particular search query, and thus, the literature search in this review cannot be considered entirely comprehensive [58]”
“In this review, the inclusion of studies was partially based on the overall citation count of each study. This was a pragmatic approach, and the number of citations is only a surrogate measure of study impact or quality, and the reliability and accuracy of this measure is debatable.”
“For the reasons above, we do not claim this study to be exhaustive. Nevertheless, the results and conclusions remain valid for the included studies.”
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I think that there is great value in the work. But the paper took the work and interpreted it in to a bland and useless conclusion. The authors could have pulled the good from the bad and drawn some useful conclusions. But they chose to paint all of the past studies with the same broad brush. They even took what they called bad studies and drew a conclusion. Very very unprofessional and I think it shows a bias that they probably don’t even realize that they have.
“likely exaggerated” is an unfounded conclusion, based on their own evaluation of the quality of the work. If the studies are inconclusive then the statement is a simple opinion based on bad data.
“In this review, we have explained and demonstrated that the chronic pain rates conventionally reported after inguinal hernia repair in the literature are obsolete, probably inaccurate, and likely exaggerated.”
There are other studies from years ago that have drawn similar conclusions. Some professionals, like the Carolinas group, have attempted to create new surveys/questionnaires that produce more useful data.
I just found it somewhat pointless to publish a paper that actually gives cover to any surgeon or medical device maker that wants to continue on with their bad materials and procedures. Any one of them can point to this “work” as justification for doing nothing.
When you look at the last year in sum, what started out as an overall well-meant effort to understand and improve the chronic pain from hernia repair issue seems to be petering out in to nothing.
I am going to guess that the “Guidelines” update will either be delayed indefinitely or will have essentially no substantive changes. The professional and business benefits of doing nothing are far greater than changing.
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There remains great value in this type of paper.
Its purpose is not to suggest what to do about chronic pain, but rather to explain why we don’t have sufficiently useful data and evidence in order to better understand and address the issue. The goal is to motivate change so that obtaining more useful data becomes possible.
I’ve said for some time now that we are unlikely to get ‘great’ data any time soon when trying to evaluate outcomes or compare surgical options, which is not to suggest that it is easy. It’s expensive, time consuming, and there are plenty of other obstacles.
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