Hernia Journal Special Issue on Chronic Pain

[Good intentions]

The special issue/collection on chronic pain after hernia repair is out now. Some of the articles are open access, some are pay-per-view. I have posted links to several of them in the past.

I have not looked through all of them but I don’t see any signs that there are suggestions for improving outcomes, identifying possible causes, or recommending that certain products or methods be avoided. It looks like the typical report of how things are now, confirming the seriousness of the problem, but not suggesting a path forward. Even Dr. Campanelli’s editorial is deflating, as it comes close to victim-blaming in its tone, and falls back on the large number of surgeries performed as somehow justifying the large number of chronic pain cases. Ignoring the concept of percentages or ratios.

Anyway, it is a decent summary of the current state-of-the-situation from professionals in the field.

https://link.springer.com/journal/10029/volumes-and-issues/27-1

[Watchful]

Whenever I see these 10-20% chronic pain rates, I’m shocked. That’s an order of magnitude higher than what surgeons typically quote (I’ve actually encountered a few surgeons who claim 0%.) Also, it seems just unacceptably high. I know it’s all levels of chronic pain, and not necessarily severe or debilitating pain, but, still, it’s crazy high.

[Good intentions]

Here is the next. For some reason the authors decided to consider pelvic prolapse mesh, aka transvaginal mesh, pain along with inguinal hernia repair mesh. An example of how generalized the knowledge of mesh is for so many surgeons.

This one looks at results after revision surgery for pain. Another after-the-fact study with no recommendations for prevention. Business is good, many return customers.

The Conclusion only mentions inguinal hernia repair but seems very illogical. 70 months is almost six years. Are they suggesting that a suffering patient wait six years before having surgery? The fact popped out from the statistical analysis apparently. Does not seem of much use. They do use it to suggest that pain relief is still possible after many years. That is the logical conclusion.

https://link.springer.com/article/10.1007/s10029-023-02748-5

Prediction of successful revision surgery for mesh-related complaints after inguinal hernia and pelvic organ prolapse repair
K. L. C. Van Rest, M. J. C. A. M. Gielen, L. M. Warmerdam, C. R. Kowalik, J. P. W. R. Roovers & W. A. R. Zwaans
Hernia (2023

“Purpose
With this retrospective case series, we aim to identify predictors for reduction of pain after mesh revision surgery in patients operated for inguinal hernia or pelvic organ prolapse with a polypropylene implant. Identifying these predictors may aid surgeons to counsel patients and select appropriate candidates for mesh revision surgery.

…

Conclusion
A longer duration of at least 70 months between implantation of inguinal mesh and revision surgery seems to give a higher chance on improvement of pain. Caregivers should not avoid surgery based on a longer duration of symptoms when an association between symptoms and the location of the mesh is found.”

[Good intentions]

Here are a couple more articles. Looks like some will be pay-per-view and some will be open access.

So far, nothing very useful seems to be coming from these articles. It might be why Dr. Campanelli was so resigned and dismissive in his last editorial. There are no paths to improvement being created, and the papers just seem to accentuate the chaos. But each one identifies CPIP as a real problem.

This one says that TEP, Dr. Towfigh’s favored method, has an 11.9% CPIP rate. Overall, the paper just compares four ways to use mesh. The results are from 2011 to 2021, from a French hernia registry, the French Hernia Registry.

https://link.springer.com/article/10.1007/s10029-023-02737-8

“Results
After PS matching analysis, Lichtenstein group showed disadvantage over TIPP, TAPP and TEP groups with significantly more CPIP at one year (15.2% vs 9.6%, p?<?0.0001; 15.9% vs. 10.0%, p?<?0.0001 and 16.1% vs. 12.4%, p?=?0.002, respectively). The 1-year CPIP rates were similar comparing TIPP versus TAPP and TEP groups (9.3% vs 10.5%, p?=?0.19 and 9.8% vs 11.8%, p?=?0.05, respectively). There was significantly less CPIP rate after TAPP versus TEP repair (1.00% vs 11.9%, p?=?0.02).”

[Good intentions]

Here is the latest article from the new Special Issue. It is about “autoimmunity”, a word that describes when the body develops an autoimmune problem. The conclusion is that mesh does not appear to cause an autoimmune condition. The chronic pain and discomfort results solely from the body’s foreign body reaction to the mesh. It is a physical problem tied to the mesh. Which fits with the result that the problems disappear when the mesh is removed.

It is an interesting article that clarifies the problem, but, again, does not offer a solution or a way to prevent it. So far, the releases for the Special Issue only seem to confirm the problem.

https://link.springer.com/article/10.1007/s10029-023-02749-4

Review
Open Access
Published: 04 February 2023
Autoimmunity and hernia mesh: fact or fiction?
B. Jisova, J. Wolesky, Z. Strizova, A. de Beaux & B. East
Hernia (2023)

The authors confirm the ~15% chronic pain rate –

“The use of synthetic mesh in hernia repair is well-established [1, 2]. Indeed, hernia guidelines recommend mesh in most hernias to minimise hernia recurrence. Local complications are well described clinically yet they are not quite so well understood from the histological perspective [10]. For example, it is known that approximately 10–20% of patients after inguinal hernia repair suffer from chronic pain to some degree [5, 35]. However, causes of this pain are variable and most likely linked to nerve injury rather than to mesh-related autoimmunity. To add to this confusion, many authors incorrectly mix autoimmunity and chronic foreign body reaction.

…

Conclusion
Currently, there is little evidence that the use of polypropylene mesh can lead to autoimmunity. A large number of potential triggers of autoimmunity along with the genetic predisposition to autoimmune disease and the commonality of hernia, make a cause and effect difficult to unravel at present. Biomaterials cause foreign body reactions, but a chronic foreign body reaction does not indicate autoimmunity, a common misunderstanding in the literature.”

[Good intentions]

Here is a link to Hernia’s web site. They list the latest articles on the page. They also show the latest Journal that has been released. January 2023 has not been released yet.

https://www.springer.com/journal/10029

Here is a link to a Topic about the Hernia Editor’s original introduction to the project.

https://herniatalk.com/forums/topic/acknowledgement-that-chronic-pain-is-real-by-the-editor-in-chief-of-hernia/

Acknowledgement that chronic pain is real by the Editor-in-Chief of Hernia