16% pain across the board – open mesh hernia repair 2020 paper

Hernia Discussion Forums Hernia Discussion 16% pain across the board – open mesh hernia repair 2020 paper

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    • #28038
      Good intentions

      Here is a recent paper that compares three different types of mesh using what looks like a well-developed questionnaire. They found that the type of mesh did not affect the pain rate, it was about 16% for all three. It seems to be very well done, even, probably, minimizing the problem a bit.

      The procedure compared was open Lichtenstein. The follow-up was one year. It’s interesting that the cutoff level in their questionnaire was “level 3 – pain present, cannot be ignored, but does not interfere with everyday activities.” Levels 1 – 3 were considered “no pain” even though “pain present cannot be ignored” is right there in the description of Level 3. I guess they tried to “down play” the results, they were bad enough as-is.

      It is an easy read, even for those not expert in statistics. The world needs more work like this, followed by actions to make things better.

      The case for laparoscopy cannot be made either, until they have done work like this. absence of data does not mean absence of problems.


      Excerpt –
      “The question put to the patient was: ‘Grade the worst pain you have felt in the operated groin during the past week’. Pain was graded on a scale from 1 to 7: level 1 – no pain; level 2 – pain present, but easily ignored; level 3 – pain present, cannot be ignored, but does not interfere with everyday activities; level 4 – pain present, cannot be ignored, and interferes with concentration on everyday activities; level 5 – pain present, interferes with most activities; level 6 – pain present, necessitating bed rest; and level 7 – pain present, prompt medical advice sought. Levels 1–3 were considered to indicate no pain, and levels 4–7 to represent pain. Significant persistent pain 1 year after surgery was set at a level of at least 4.”

    • #28058
      Good intentions

      I missed a point that would be more important to those under 50 years of age. 19% of people under 50 had chronic pain at one year.

      Excerpt from the conclusion and results abstract –

      “Results: In total, 23259 male patients provided data for analysis (response rate 70⋅6 per cent). Rates of chronic pain after repairs using regular polypropylene lightweight mesh, composite (poliglecaprone-25) polypropylene lightweight mesh and polypropylene heavyweight mesh were 15⋅8, 15⋅6 and 16⋅2 per cent
      respectively. Adjusted multiple logistic regression analysis showed no significant differences between regular (odds ratio (OR) 0⋅98, 95 per cent c.i. 0⋅90 to 1⋅06) or composite (OR 0⋅95, 0⋅86 to 1⋅04) lightweight mesh versus heavyweight mesh. The most striking risk factor for chronic pain was young age; 19⋅4 per cent of patients aged less than 50years experienced pain 1year after hernia repair (OR 1⋅43, 1⋅29 to 1⋅60).
      Conclusion: Patient-reported chronic pain 1year after open mesh repair of inguinal hernia was common, particularly in young men. The risk of developing chronic pain was not influenced by the type of mesh.”

    • #28060
      Good intentions

      They also noted that if they raised the minimum level to 5, they still had 11% of people that had reported pain. Level’s 5, 6 and 7 are shown below. So, 11% of people had pain that interfered with most activities, if I read it right.

      Excerpt –

      “Changing the definition of pain to a score of at least 5
      resulted in a chronic pain rate across the whole cohort
      of 11⋅1 per cent, with no significant difference between
      the mesh groups.

      …level 5 – pain present, interferes with most activities, level 6 – pain present, necessitating bed rest; and level 7 – pain present, prompt medical advice sought.”

    • #28135

      Thank you for this. When I was considering surgery after @3 years of living with the ‘bulge’, which rarely (almost never) gave me any pain, I was aware of the possibility of chronic pain, but the numbers were low so I wasn’t worried. Now, the only comment I would make on this study is that their totals are wrong: 16 % is too low, from all I’ve read and heard.
      Also, it’s interesting that the cut-off time was one year. Let’s hope they aren’t assuming that the numbers will go down after a year-if so, they are being optimistic. I wish someone would do a similar study with dates of two, or three, or five years.

    • #28136

      What I think nobody knows is what the reaction of the mesh might be after few/many years, based on age/life style, activity level (also including athletes here): can one assume that very rarely problems will arise after few years from the mesh surgery with no pain? or are we looking at a potential time bomb?

    • #28137

      The long term stuff is really interesting, though sparse. On the one hand, I’ve seen evidence that the longer one waits, the more improvement one sees. Saw one study suggesting after 5 years, the numbers continue fo drop, and then by ten years almost no one complains of life-altering pain and discomfort. Then I’ve seen a lot of anecdotal evidence suggesting that pain and discomfort can actually start years and years later after an injury or damage to the area or migration or infection, etc etc. Dr. Bendavid in an interview I saw said something like ‘it can take 5 to as many as 17 years’ for pain to mostly go away. Thought that was interesting. I’m guessing that the body has a way of dealing with pain so that along really long time horizons it does in fact diminish. But the area with mesh will also always be subject to injury or infection (however unlikely) as well, so problems can begin at any time. I think the latter is much less likely. And of course who wants to deal with pain and discomfort for a decade or longer in the cases of those who have had pin since surgery. And I’m sure there may be some situations where there won’t be improvement no matter what without intervention.

    • #28138

      We don’t read much about pain related to non-mesh repairs.

    • #28139

      “The Shouldice technique is a four-layer darn of stainless steel wire. This conceptually is a stainless-steel mesh that is formed in situ. This would explain why there is no difference in chronic pain with the randomised trials.”

    • #28140

      Addressing your statement that there are probably some situations that won’t see improvement without intervention, someone having a reaction to the mesh is one of those situations. Your body is in a constant state of inflammation and, in my case, debilitating pain! I am happy for those that get resolution without intervention. Every subsequent surgery is harder to heal from. I’m hoping to get my final fix one day, when we can figure out the best solution for someone that is prone to mesh reaction AND recurrent hernias, due to collagen disorder. Dr. Towfigh is good at solving these problems!

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