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Copyright (c) 2021 Slovenian Medical Journal. This work is licensed under a
Creative Commons Attribution-NonCommercial 4.0 International License.
The incidence of chronic postoperative pain after major 
abdominal surgery
Incidenca kronične pooperativne bolečine po velikih abdominalnih operacijah
Matej Jenko, Neva Požar-Lukanović, Vesna Novak-Janković, Alenka Spindler-Vesel
Abstract
Background: Chronic postoperative pain, pain that cannot be explained by other causes and that persist more than 2 
months after surgery, occurs in 10-50% of patients after major abdominal surgery. Its subgroup, chronic neuropathic pain 
is very resistant to treatment. Intraoperative application of epidural analgesia and infusion of dexmedetomidine may infl-
luence the incidence of chronic postoperative pain.
Method: Adult surgical patients from the Clinical Department of Abdominal Surgery, UMC Ljubljana, who were planned to 
undergo one of the following procedures: stomach surgery, pancreas surgery or large intestinal resections, were included 
in this prospective study. All patients had epidural analgesia and intraoperative dexmedetomidine infusion. Three months 
after the procedure, structured questionnaire was sent to the patients. The intensity and quality of pain were assessed. 
DN4 (Douleur Neuropathique 4) and painDetect questionnaires were used.
Results: We have received 42 (50%) properly filled DN4 questionnaires and 45 (53%) pain detect questionnaires. The in-
cidence of chronic pain in our study was 25%, 7.1% of them had features of neuropathic pain (3 patients met criteria for 
neuropathic pain according to DN4).
Conclusion: Our prospective study suggests a possible favourable impact of intraoperative epidural analgesia and dexme-
detomidine infusion on the incidence of chronic postoperative pain.
Izvleček
Uvod: O kronični pooperativni bolečini govorimo, kadar ne najdemo drugega vzroka za njen nastanek in ko traja dlje kot 2 
meseca po operaciji. Pojavi se pri 10-50 % bolnikov po velikih abdominalnih operacijah. Podskupina kronične bolečine, ki 
jo je najtežje zdraviti, je kronična nevropatska bolečina. Medoperativna epiduralna analgezija in infuzija deksmedetomidi-
na lahko vplivata na incidenco kronične pooperativne bolečine in na incidenco nevropatske bolečine.
Department of anaesthesiology, Division of Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
Correspondence / Korespondenca: Matej Jenko, e: matej.jenko@kclj.si
Key words: dexmedetomidine; neuropathic pain; abdominal surgery
Ključne besede: deksmedetomidin; nevropatska bolečina; abdominalne operacije
Received / Prispelo: 18. 5. 2020 | Accepted / Sprejeto: 11. 11. 2020
Cite as / Citirajte kot: Jenko M, Požar-Lukanović N, Novak-Janković V, Spindler-Vesel A. The incidence of chronic postoperative pain after 
major abdominal surgery. Zdrav Vestn. 2021;90(11–12):596–602. DOI: https://doi.org/10.6016/ZdravVestn.3086
eng slo element
en article-lang
10.6016/ZdravVestn.3086 doi
18.5.2020 date-received
11.11.2020 date-accepted
Anaesthesiology, intensive care Anesteziologija, intenzivna nega discipline
Short scientific article Kratki znanstveni prispevek article-type
The incidence of chronic postoperative pain 
after major abdominal surgery
Incidenca kronične pooperativne bolečine po 
velikih abdominalnih operacijah article-title
The incidence of chronic postoperative pain 
after major abdominal surgery
Incidenca kronične pooperativne bolečine po 
velikih abdominalnih operacijah alt-title
dexmedetomidine, neuropathic pain, abdom-
inal surgery
deksmedetomidin, nevropatska bolečina, abdom-
inalne operacije kwd-group
The authors declare that there are no conflicts 
of interest present.
Avtorji so izjavili, da ne obstajajo nobeni 
konkurenčni interesi. conflict
year volume first month last month first page last page
2021 90 11 12 596 602
name surname aff email
Matej Jenko 1 matej.jenko@kclj.si
name surname aff
Neva Požar-Lukanović 1
Vesna Novak-Janković 1
Alenka Spindler-Vesel 1
eng slo aff-id
Department of anaesthesiology, 
Division of Surgery, University 
Medical Centre Ljubljana, 
Ljubljana, Slovenia
Klinični oddelek za anestezijo in 
intenzivno terapijo operativnih 
strok, Kirurška klinika, 
Univerzitetni klinični center 
Ljubljana, Ljubljana, Slovenija
1
Slovenian Medical Journallovenian Medical Journal
597
SHORT SCIENTIFIC ARTICLE
The incidence of chronic postoperative pain after major abdominal surgery
1 Introduction
A significant amount of research is focused on the 
study of chronic postoperative pain, that is, pain that 
cannot be explained by another cause and that lasts for 
more than two months after surgery (1). Transient   yet 
persistent pain caused by nerve damage can appear af-
ter surgery, however, other factors must also be present. 
Nerve damage will occur with each surgical procedure, 
but not all patients will develop persistent chronic pain. 
The following conditions increase the risk of chronic 
postoperative pain: previous pain (tolerance to opioids, 
hyperexcitability of the central nervous system), physical 
nerve damage (location of surgery, surgical technique), 
severe postoperative pain (inadequate analgesia, exten-
sive tissue damage), depression, gender, genetics, delayed 
nerve regeneration (chemotherapy, radiation) (2).
Severe postoperative pain can cause hormonal and 
metabolic stress reactions, potentially leading to cardio-
vascular or other complications (3). Therefore, it is nec-
essary to optimally treat perioperative pain early, inhibit 
the injury-induced transmission of the pain stimulus, 
and reduce the autonomic and somatic reflex response 
to pain. Epidural analgesia is optimal for major abdom-
inal operations, as it has a lower endocrine and meta-
bolic stress response compared to intravenous analgesia 
(4-10).
In chronic postoperative pain, the neuropathic com-
ponent of pain is often present. It is characteristic of this 
form that transduction (change of a nociceptive stimulus 
into an electrical impulse) is missing in the physiological 
process of pain formation. This type of pain is difficult 
to treat due to changes in neurotransmitter and recep-
tor characteristics along somatosensory and descending 
modulatory pathways (11). After abdominal surgery, 
chronic pain occurs in 10-50% of patients, of which up 
to 25% display the characteristics of neuropathic pain 
(12,13).
Metode: V prospektivno raziskavo smo vključili odrasle kirurške bolnike, sprejete na KO za abdominalno kirurgijo, pri 
katerih je bila načrtovana operacija želodca, operacija trebušne slinavke ali operacija črevesja. Vsi bolniki so imeli epidu-
ralno analgezijo in medoperativno infuzijo deksmedetomidina. Tri mesece po operaciji smo bolnikom poslali vprašalnike. 
Ocenjevali smo jakost in vrsto bolečine. Za oceno smo uporabili DN4 (Douleur Neuropathique 4) in vprašalnik painDetect.
Rezultati: Prejeli smo 42 (50 %) pravilno izpolnjenih vprašalnikov DN4 in 45 (53 %) vprašalnikov painDetect. V naši razi-
skavi je bila incidenca kronične bolečine 25 %, nevropatske bolečine 7,1 % (3 bolniki so izpolnjevali merila za nevropatsko 
bolečino po vprašalniku DN4).
Zaključek: Rezultati naše prospektivne raziskave nakazujejo, da bi lahko medoperativna uporaba epiduralne analgezije in 
infuzije deksmedetomidina zmanjšala pojav pooperativne kronične bolečine.
Chronic pain appears most frequently after amputa-
tions and inguinal hernia, breast, gallbladder and lung 
operations, but it can also appear after other types of 
surgery (14).
Perioperative epidural analgesia in combination with 
ketamine infusion has a beneficial effect on the reduc-
tion of acute postoperative pain and on the occurrence 
of chronic postoperative pain 12 months after surgery in 
patients who have undergone abdominal surgery (15). 
The usefulness of epidural analgesia itself has been con-
firmed by other studies (16).
Dexmedetomidine, a selective alpha-2 adrenoceptor 
agonist, reduces the interoperative use of anaesthetics, 
reduces the perioperative release of catecholamines and 
has anti-inflammatory activity (17-19). Peripheral ad-
ministration of dexmedetomidine reduces mechanical 
and thermal hyperalgesia and postoperative pain (20).
Several studies have confirmed the beneficial effect 
of epidural analgesia or dexmedetomidine on the inci-
dence of chronic postoperative pain in major abdominal 
surgery. The purpose of our study was to determine the 
incidence of chronic postoperative pain and neuropath-
ic pain in patients who underwent major abdominal sur-
gery and also received epidural analgesia and intraoper-
ative dexmedetomidine infusion.
By monitoring various major abdominal operations, 
we could infer whether there were any differences in the 
incidence of chronic pain with respect to specific laparo-
scopic abdominal operations, the duration of surgery or 
complications.
2 Methods
The study involved 84 adult patients with an ASA 
(American Society of Anaesthesiologists) physical sta-
tus classification score of 2-3 who underwent major 
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abdominal surgery (laparoscopic gastric, intestinal or 
pancreatic surgery) at the Department of Abdominal 
Surgery at the Medical Centre Ljubljana. Prior to sur-
gery, a team member spoke with the patient obtaining 
their written consent. Patients with contraindications 
to epidural anaesthesia or planned postoperative ad-
mission to the intensive care unit (ICU) were not in-
cluded in the study.
Upon admission to the operating theatre, an ECG 
was recorded, a cuff for non-invasive blood pressure 
measurement and pulse oximetry were set, intravenous 
cannulation was performed and a dexmedetomidine 
infusion (0.5 µg / kg / hour) was set. The epidural cath-
eter was inserted in the left lateral position (Th 7-8, Th 
9-10 for low anterior resection). For the introduction of 
anaesthesia, we used fentanyl or sufentanil, propofol or 
etomidate and rocuronium.
During surgery, we maintained normocapnia, nor-
moxemia and normothermia.
Anaesthesia was maintained intravenously (with 
propofol and dexmedetomidine). The amount of 
propofol was titrated according to the value of the 
bispectral index (BIS). Analgesia was maintained with 
an epidural dose of levobupivacaine and sufentanil. If 
no additional analgesia was required during surgery, 
the epidural block was effective. Patients with insuffi-
cient epidural block were excluded from the study. A 
continuous epidural infusion of a local anaesthetic was 
set up during surgery, which the patients could self-reg-
ulate after surgery (patient control epidural analgesia, 
PCEA) (0.125% levobupivacaine 200 mL, morphine 4 
mg, clonidine 0.075 mg; infusion rate 5 mL/h, bolus 5 
mL, lockout time 30 minutes).
Muscle relaxation was monitored using TOF (Train 
of Four) and rocuronium dosage was administered 
as required. All patients received an intraoperative 
antiemetic.
The muscle block was interrupted with sugamma-
dex or neostigmine at the end of surgery, according to 
the measured TOF values. 
Toward the conclusion of surgery during the lap-
arotomy closure, the dexmedetomidine infusion was 
stopped.
After surgery, the patients were monitored in the 
post-anaesthesia care unit and later transferred to the 
Department of Abdominal Surgery ICU.
Three months after the procedure, we sent each pa-
tient a DN4 (Douleur Neuropathique 4) and a pain-
Detect questionnaire (20,21) to assess the intensity 
and quality of pain. We compared the responses of the 
painDetect questionnaire with the SF 36 questionnaire, 
which allowed us an approximate assessment of chron-
ic pain (22). The collected responses were statistically 
processed with the IBM SPSS software 25 (New York, 
USA). The value of p <0.05 was deemed statistically 
significant.
The study was approved by the Republic of Slo-
venia National Medical Ethics Committee (number 
107/10/13, date of approval: 06.12.2013) and was regis-
tered on ClinicalTrials.gov (NCT02293473).
laparotomy. Laparoscopic surgeries were not included in 
the study. The incidence of chronic pain was 25% (11 
patients), the characteristics of neuropathic pain were 
reported by three patients 7.1%.
4 Discussion
Chronic postoperative pain was present in 25% of 
patients in our study, which is consistent with data from 
the literature (22).
The incidence of neuropathic pain was 7.1% and 
none of the patients rated their pain at more than 7 on a 
numerical scale of pain, which is a slightly lower propor-
tion in terms of intensity and proportion of neuropathic 
Description of the type of pain or sensory dysfunction Number of patients with a positive response (%)
Burning pain 3 (7.1)
Painful cold 2 (4.8)
Electric sock 1 (2.4)
Tingling 11 (26.2)
Pins and needles 4 (9.5)
Numbness 2 (4.8)
Itching 4 (9.5)
Hypoesthesia to touch 0 (0)
Hypoesthesia to pinprick 0 (0)
Pain increased by brushing 0 (0)
Presence of four or more signs in the same patient (meets the 
criteria for neuropathic pain) 3 (7.1)
Table 1: Sensory dysfunction frequency, answers to the DN4 questionnaire.
Variable Mean (standard deviation), minimum - maximum
Pain intensity at a particular time 1.2 (± 1.4), 0 - 5
Most severe pain in the last four weeks 5.3 (± 2.7), 1 - 10
Average pain in the last four weeks 2.2 (± 1.6), 0 - 7
Table 2: The painDetect questionnaire analysis (numerical scale from 0 to 10).
Variable Frequency (%)
Persistent pain with slight fluctuations 12 (26.7)
Persistent pain with pain attacks 19 (42.2)
Pain attacks without pain between them 6 (13.3)
Pain attacks with pain between them 4 (8.9)
Missing answers 4 (8.9)
Table 3: Type of pain according to the painDetect questionnaire.
Type of surgery Gastric surgery Bowel surgery
Number of patients 16 26 Total 42
Duration of surgery 123 min (IQR 35 min) 130 min (IQR 40 min) p=0.122 (Mann - Whitney U test)
Number of patients admitted to the ICU 1 0 p=0.381 (chi-squared test)
Number of patients re-admitted to the 
ICU 1 5 p=0.380 (chi-squared test)
Number of patients with insulin-
dependent diabetes (number of these 
patients with neuropathic pain)
3 (0) 2 (1) p=0.352 (chi-squared test)
Average length of hospital stay 9 (IQR 3) 9 (IQR 4,5) p= 0.651 (Mann - Whitney U test)
Number of patients who met the criteria 
for neuropathic pain 2 1 p=0.547 (chi-squared test)
Table 4: Results for a subset of patients in the study.
Legend: IQR – interquartile range.
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The incidence of chronic postoperative pain after major abdominal surgery
3 Results
Of the 84 patients who were sent questionnaires, we 
received 45 (53%) responses. 42 (50%) patients returned 
both the DN4 and painDetect questionnaires fully com-
pleted. The results are presented in Tables 1, 2, and 3. Of 
those who returned both, the mean age was 65 (± 12) 
years; average weight 64 (± 10 kg). 17 had an ASA score 
of 2, and 25 had an ASA score of 3. 20 (48%) were male, 
and 22 (53%) were female. Two of the 84 patients had 
pancreatic surgery but did not return the questionnaires. 
The results for the other two subgroups of patients (pa-
tients after gastric surgery and after bowel surgery) are 
in Table 4. All patients included underwent surgical 
laparotomy. Laparoscopic surgeries were not included in 
the study. The incidence of chronic pain was 25% (11 
patients), the characteristics of neuropathic pain were 
reported by three patients 7.1%.
4 Discussion
Chronic postoperative pain was present in 25% of 
patients in our study, which is consistent with data from 
the literature (22).
The incidence of neuropathic pain was 7.1% and 
none of the patients rated their pain at more than 7 on a 
numerical scale of pain, which is a slightly lower propor-
tion in terms of intensity and proportion of neuropathic 
Description of the type of pain or sensory dysfunction Number of patients with a positive response (%)
Burning pain 3 (7.1)
Painful cold 2 (4.8)
Electric sock 1 (2.4)
Tingling 11 (26.2)
Pins and needles 4 (9.5)
Numbness 2 (4.8)
Itching 4 (9.5)
Hypoesthesia to touch 0 (0)
Hypoesthesia to pinprick 0 (0)
Pain increased by brushing 0 (0)
Presence of four or more signs in the same patient (meets the 
criteria for neuropathic pain) 3 (7.1)
Table 1: Sensory dysfunction frequency, answers to the DN4 questionnaire.
Variable Mean (standard deviation), minimum - maximum
Pain intensity at a particular time 1.2 (± 1.4), 0 - 5
Most severe pain in the last four weeks 5.3 (± 2.7), 1 - 10
Average pain in the last four weeks 2.2 (± 1.6), 0 - 7
Table 2: The painDetect questionnaire analysis (numerical scale from 0 to 10).
Variable Frequency (%)
Persistent pain with slight fluctuations 12 (26.7)
Persistent pain with pain attacks 19 (42.2)
Pain attacks without pain between them 6 (13.3)
Pain attacks with pain between them 4 (8.9)
Missing answers 4 (8.9)
Table 3: Type of pain according to the painDetect questionnaire.
Type of surgery Gastric surgery Bowel surgery
Number of patients 16 26 Total 42
Duration of surgery 123 min (IQR 35 min) 130 min (IQR 40 min) p=0.122 (Mann - Whitney U test)
Number of patients admitted to the ICU 1 0 p=0.381 (chi-squared test)
Number of patients re-admitted to the 
ICU 1 5 p=0.380 (chi-squared test)
Number of patients with insulin-
dependent diabetes (number of these 
patients with neuropathic pain)
3 (0) 2 (1) p=0.352 (chi-squared test)
Average length of hospital stay 9 (IQR 3) 9 (IQR 4,5) p= 0.651 (Mann - Whitney U test)
Number of patients who met the criteria 
for neuropathic pain 2 1 p=0.547 (chi-squared test)
Table 4: Results for a subset of patients in the study.
Legend: IQR – interquartile range.
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pain than in comparable studies (1,12,13). The DN4 and 
painDetect questionnaires indicated that most pain pat-
terns are not of neuropathic origin (Table 3) (23). Dif-
ferent studies have used different, directly incomparable 
methods, which, however, describe a higher incidence of 
chronic postoperative pain than in our study. In a study 
by Joris et al., the incidence was 17% after laparoscopic 
colorectal surgery and similarly after laparotomies (12). 
In laparoscopic gynaecological operations, the report-
ed incidence of clinically significant neuropathic pain 
is low at approximately 5%. It occurs due to damage to 
the iliohypogastric-ilioinguinal nerve when suturing the 
fascia, which occurs less frequently than in open surgery 
(24). Persistent postoperative neuropathic pain remains 
a poorly recognized clinical problem. The chronicity and 
persistence of this type of pain is often very limiting and 
has a strong impact on the patient, both psychologically, 
physically, economically and emotionally (25).
The results of other research show that epidural anal-
gesia significantly reduces the incidence of chronic neu-
ropathic postoperative pain, to 17.6% (16). This is higher 
with epidural analgesia than in our study, possibly in-
dicating the beneficial effect of dexmedetomidine. Our 
patient’s mean age was higher than in other studies, and 
the incidence of chronic postoperative pain is increased 
in elderly patients. However, patients requiring postop-
erative intensive care in whom the incidence of chronic 
and neuropathic pain is higher (26) were excluded from 
our study. Some studies report a comparable incidence 
of chronic neuropathic pain with epidural analgesia 
alone (22,27).
The lower incidence of postoperative chronic pain 
could be affected by the beneficial effect of dexmede-
tomidine infusion during surgery (20). Its analgesic 
component is mediated through spinal and supraspinal 
mechanisms, as α2 adrenergic receptors are found in the 
brain in the locus coeruleus and in the posterior horns 
of the spinal cord. Binding of dexmedetomidine to the 
α2 adrenergic receptor activates the G protein, which 
prevents calcium from entering the cell, inhibiting the 
release of norepinephrine. At the same time, potassium 
ions enter the cell, which reduces the cell’s susceptibility 
to depolarization and thus inhibits the transmission of 
pain stimuli (28-30). The main analgesic effect of dex-
medetomidine is its action on α2 adrenergic receptors 
in the locus coeruleus (28,29). After nerve damage, it 
reduces hyperalgesia and inhibits microglia activation 
and signal-regulated kinase in the dorsal horn of the 
spinal cord (18,19). The anti-inflammatory effect of dex-
medetomidine is also beneficial (31). By stimulating α2 
adrenergic receptors and inhibiting necrosis factor κB, 
it inhibits the release of inflammatory cytokines, partic-
ularly interleukin 6, interleukin 8, and tumour necrosis 
factor α (32-37).
We did not find differences in the incidence of chron-
ic postoperative pain in the individual subgroups of 
patients (gastric, bowel surgery). The level of epidural 
catheter insertion depended on the expected surgery 
level and maximum pain. However, the type of surgery 
itself, its duration and postoperative complications do 
not show differences in the incidence of chronic post-
operative or neuropathic pain. Our sample size was too 
small to analyze the effect of comorbidities on chron-
ic postoperative pain (13,23). The literature data shows 
that one in five patients (20%) with insulin-dependent 
diabetes develops chronic postoperative pain.
4.1 Study limitations
In our study, 53% of patients returned the question-
naires. There is a possibility that responses were sent on-
ly by patients who had a favourable surgical treatment 
outcome, giving falsely positive results. Due to the small 
sample size, it was relatively difficult to estimate the ex-
pected confidence interval of the incidence of chronic 
pain. Patients with chronic neuropathic pain can dis-
play specific symptoms: depression, sleep disorders and 
similar disorders are more common, which may explain 
why some patients did not return their questionnaires. 
This could increase the incidence of neuropathic pain by 
a factor of 4 and, accordingly, the incidence of chronic 
postoperative pain. In our study, we also did not analyze 
psychological factors such as depression, which plays an 
important role in the development of chronic postoper-
ative pain. Due to the observational nature of the study, 
it was not possible to estimate the proportional contri-
butions of epidural analgesia or dexmedetomidine to the 
reduction of chronic postoperative pain. Compared to 
foreign studies, a possible beneficial effect of a different 
surgical technique cannot be ruled out.
5 Conclusion
The purpose of our study was to assess the incidence 
of postoperative chronic pain and neuropathic pain after 
major abdominal surgery. The results of our study might 
indicate a beneficial effect of perioperative epidural anal-
gesia and dexmedetomidine on the incidence of chronic 
postoperative pain.
Conflict of interest
None declared.
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The incidence of chronic postoperative pain after major abdominal surgery
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