H Kehlet

Copenhagen University Hospital, København, Capital Region, Denmark

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Publications (871)2920.31 Total impact

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    ABSTRACT: Variability in heart rate response (HRR) can be used as a measure for autonomic nervous system function, which may influence sleep disturbances and the recovery phase after major surgery. The aim of this study was to evaluate autonomic function by assessment of HRR during sleep arousals in the postoperative period after fast-track hip and knee arthroplasty. Determination of autonomic function was gained from polysomnographic evaluation of 10 patients >60 years undergoing either hip or knee arthroplasty (mean age 69.9 years) evaluating HRR during the different sleep phases. Sleep monitoring took place in the patients' home preoperatively, during hospitalization on the first postoperative night, and on the fourth postoperative night at home. HRR was reduced (P < 0.01) during arousal from non-REM stage 2 sleep on the first postoperative night, and was still reduced on the fourth postoperative night compared to preoperative level (P = 0.01). HRR during arousal from REM sleep was not different between the preoperative and fourth postoperative night (P = 0.92), while this could not be determined on the first postoperative night where REM sleep disappeared. The reduced HRR during sleep arousal after major arthroplasty surgery in elderly patients may reflect a functional change in sympathetic nervous system potentially relevant for postoperative sleep changes, fatigue and cognitive function.
    Sleep and Biological Rhythms 03/2015; · 1.05 Impact Factor
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    ABSTRACT: Persistent postoperative pain is a well-established clinical problem with potential severe personal and socioeconomic implications. The prevalence of persistent pain varies across surgery types. Severe persistent pain and related impairment occur in 5% to 10% of patients after groin hernia repair. The substantial interindividual variability in pain-related phenotypes within each surgery type cannot be explained by environmental factors alone, suggesting that genetic variation may play a role. We investigated the contribution of COMT and GCH1 to persistent postherniotomy pain (PPP)-related functional impairment. Prospective data from 429 Caucasian male patients with hernia were collected. Three COMT and 2 GCH1 tagging single-nucleotide polymorphisms (SNPs) were genotyped and analyzed for association with PPP-related activity impairment at 6 months after herniotomy. Fifty-five (12.8%) patients had moderate-to-severe pain-related activity impairment 6 months postoperatively as measured by Activity Assessment Scale (≥8.3). Patients with the G allele of COMT SNP rs6269 and C allele of COMT SNP rs4633 had less impairment (P = 0.03 and 0.01, respectively); in addition, the COMT haplotype GCG was associated with less impairment. For GCH1, the A allele of SNP rs3783641, T allele of rs8007267, and AT haplotype showed a protective effect trend (although nonsignificant; P = 0.08, 0.06, and 0.08, respectively). A prediction model of substantial PPP-related activity impairment, combining COMT and GCH1 SNPs with clinical, psychophysical, and psychological risk factors, had a "good" (0.8 < area under curve < 0.9) discriminatory power. These data suggest that functional variations in COMT and GCH1 combined with clinical factors are predictive of PPP-related impairment after groin herniotomy.
    Pain 02/2015; 156(2):273-9. · 5.64 Impact Factor
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    ABSTRACT: Background The mesh fixation technique in laparoscopic incisional hernia repair may influence the rates of hernia recurrence and chronic pain. This study investigated the long-term risk of recurrence and chronic pain in patients undergoing laparoscopic incisional hernia repair with either absorbable or non-absorbable tacks for mesh fixation.Methods This was a nationwide consecutive cohort study based on data collected prospectively concerning perioperative information and clinical follow-up. Patients undergoing primary, elective, laparoscopic incisional hernia repair with absorbable or non-absorbable tack fixation during a 4-year interval were included. Follow-up was by a structured questionnaire regarding recurrence and chronic pain, supplemented by clinical examination, and CT when indicated. Recurrence was defined as either reoperation for recurrence or clinical/radiological recurrence.ResultsOf 1037 eligible patients, 84·9 per cent responded to the questionnaire, and 816 were included for analysis. The median observation time for the cohort was 40 (range 0–72) months. The cumulative recurrence-free survival rate was 71·5 and 82·0 per cent after absorbable and non-absorbable tack fixation respectively (P = 0·007). In multivariable analysis, the use of absorbable tacks was an independent risk factor for recurrence (hazard ratio 1·53, 95 per cent c.i. 1·11 to 2·09; P = 0·008). The rate of moderate or severe chronic pain was 15·3 and 16·1 per cent after absorbable and non-absorbable tack fixation respectively (P = 0·765).Conclusion Absorbable tack fixation of the mesh was associated with a higher risk of recurrence than non-absorbable tacks for laparoscopic mesh repair of incisional hernia, but did not influence chronic pain.
    British Journal of Surgery 02/2015; · 4.84 Impact Factor
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    ABSTRACT: Diabetes is a risk factor for postoperative morbidity, which includes total hip and knee arthroplasty. However, no previous studies have been done in a fast-track setting with optimized perioperative care, including spinal anesthesia, multimodal opioid-sparing analgesia, early mobilization, and discharge to home, which improved postoperative outcome. We performed an observational cohort study using prospective data in primary total hip and total knee arthroplasty with a standardized fast-track approach. Eight hundred ninety type 2 diabetics were successfully propensity matched with 7165 nondiabetics. Subanalyses on antihyperglycemic treatment were done using the Danish National Database of Reimbursed Prescriptions for information on dispensed prescriptions 6 months preoperatively. Length of hospital stay (LOS), 90-day readmissions, and mortality were found through the Danish National Health Registry and medical charts. Multiple logistic regression analyses on LOS > 4 days and readmissions were used to further adjust for demographics, comorbidity, and department of surgery. To further evaluate the clinical relevance of type 2 diabetes, we estimated the number of surgical type 2 diabetics needed for 1 more occurrence of LOS > 4 days or readmissions (adjusted number needed to harm [NNH]). Although more type 2 diabetics (11.3%) than nondiabetics (8.1%) had LOS > 4 days (unadjusted P = 0.001), there was no association between type 2 diabetes and LOS > 4 days when adjusting for covariates (odds ratio: 1.19 [0.93-1.54]; P = 0.172). Correspondingly, the NNH was 78 but ranged between 31 and infinity. Type 2 diabetes was not associated with 30- (1.02 [0.75-1.39]; P = 0.897) or 90-day readmissions (1.22 [0.87-1.71]; P = 0.254), and with an NNH of 957 (59-∞) and 115 (35-∞), respectively. Insulin-treated type 2 diabetes was associated with increased risk of specific "diabetes-related" morbidity (1.95 [1.13-3.35]; P = 0.016). Type 2 diabetes per se has limited influence on postoperative morbidity in fast-track total hip and knee arthroplasty.
    Anesthesia and analgesia. 01/2015; 120(1):230-8.
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    ABSTRACT: Thigh tourniquet is commonly used in total knee arthroplasty (TKA) but may contribute to pain and muscle damage. Consequently, the reduction in knee-extension strength after TKA may be caused by quadriceps muscle ischaemia underneath the cuff.
    The Knee 12/2014; · 2.01 Impact Factor
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    ABSTRACT: The choice of anaesthetic technique for patients undergoing joint arthroplasty is debatable. The hypothesis of this study was that general anaesthesia would generate a more favourable recovery profile than spinal anaesthesia. We randomly allocated 120 patients to either intrathecal bupivacaine or general anaesthesia with target-controlled infusion of remifentanil and propofol. Length of hospital stay assessed as meeting discharge criteria was the primary outcome parameter. Other outcome parameters were actual time of discharge, pain, use of rescue pain medication, blood loss, length of stay in the post-operative care unit, dizziness, post-operative nausea, need of urinary catheterisation and patient satisfaction. General anaesthesia resulted in slightly reduced length of hospital stay (26 vs. 30 h, P = 0.004), less nausea (P = 0.043) and dizziness (P < 0.001). General anaesthesia patients had higher pain scores during the first two post-operative hours (P < 0.001) but lower after 6 h compared with the spinal anaesthesia group (P < 0.01 and P < 0.05). General anaesthesia patients had better orthostatic function compared with spinal anaesthesia patients (P = 0.008). Patients in the spinal anaesthesia group fulfilled the discharge criteria from the post-operative care unit earlier compared with the general anaesthesia patients (P = 0.004). General anaesthesia patients requested a change in the method of anaesthesia for a subsequent operation less often than the spinal anaesthesia patients (5 vs. 13, P = 0.022). General anaesthesia resulted in a more favourable recovery profile compared with spinal anaesthesia. © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
    Acta Anaesthesiologica Scandinavica 12/2014; · 2.31 Impact Factor
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    ABSTRACT: We present detailed information about early morbidity after aseptic revision knee replacement from a nationwide study. All aseptic revision knee replacements undertaken between 1st October 2009 and 30th September 2011 were analysed using the Danish National Patient Registry with additional information from the Danish Knee Arthroplasty Registry. The 1218 revisions involving 1165 patients were subdivided into total revisions, large partial revisions, partial revisions and revisions of unicondylar replacements (UKR revisions). The mean age was 65.0 years (27 to 94) and the median length of hospital stay was four days (interquartile range: 3 to 5), with a 90 days re-admission rate of 9.9%, re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges of 51 to 55 years (p = 0.018), 76 to 80 years (p < 0.001) and ≥ 81 years (p < 0.001) were related to an increased risk of re-admission. The age ranges of 76 to 80 years (p = 0.018) and the large partial revision subgroup (p = 0.073) were related to an increased risk of re-operation. The ages from 76 to 80 years (p < 0.001), age ≥ 81 years (p < 0.001) and surgical time > 120 min (p < 0.001) were related to increased length of hospital stay, whereas the use of a tourniquet (p = 0.008) and surgery in a low volume centre (p = 0.013) were related to shorter length of stay. In conclusion, we found a similar incidence of early post-operative morbidity after aseptic knee revisions as has been reported after primary procedures. This suggests that a length of hospital stay ≤ four days and discharge home at that time is safe following aseptic knee revision surgery in Denmark. Cite this article: Bone Joint J 2014;96-B:1649-56. ©2014 The British Editorial Society of Bone & Joint Surgery.
    The bone & joint journal. 12/2014; 96-B(12):1649-56.
  • Henrik Kehlet
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    ABSTRACT: The concept of multimodal postoperative recovery programs, i.e., Enhanced Recovery After Surgery (ERAS) programs or “fast-track surgery”, was fostered more than 15 years ago when it was realized that unimodal interventions were futile for addressing the problem of multimodal perioperative morbidity.1 Due to initial successful results, the concept has now been accepted worldwide and across most surgical specialities. During this process, the ERAS Society (http://www.erassociety.org) has played an important role in helping to provide guidelines, educational meetings, and additional support. Therefore, based on the success of ERAS programs, it might be considered acceptable to lean back and be satisfied with the recent progress. Then again, an invitation from the Journal to publish a personal editorial view on ERAS - by someone involved from the early development phase of the program - presents an opportunity for a critical reassessment of the basic ideas behind the concept and whether we ...
    Canadian Journal of Anaesthesia 11/2014; 62(2). · 2.50 Impact Factor
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    ABSTRACT: Moderate to severe pain in the first week after axillary lymph node dissection (ALND) for breast cancer is experienced by approximately 50% of the patients. Damage to the intercostobrachial nerve (ICBN) has been proposed as a risk factor for the development of persistent pain following breast cancer surgery but with limited information on acute post-operative pain. The aim of the present study was to examine the influence of ICBN handling on pain during the first week after ALND.
    Acta Anaesthesiologica Scandinavica 11/2014; 58(10):1240-8. · 2.36 Impact Factor
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    ABSTRACT: SUMMARY Persistent pain after breast cancer surgery (PPBCS) is increasingly recognized as a potential problem facing a sizeable subset of the millions of women who undergo surgery as part of their treatment of breast cancer. Importantly, an increasing number of studies suggest that individual variation in psychosocial factors such as catastrophizing, anxiety, depression, somatization and sleep quality play an important role in shaping an individual's risk of developing PPBCS. This review presents evidence for the importance of these factors and puts them within the context of other surgical, medical, psychophysical and demographic factors, which may also influence PPBCS risk, as well as discusses potential perioperative therapies to prevent PPBCS.
    Pain management. 11/2014; 4(6):445-59.
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    ABSTRACT: Data on early morbidity and complications after revision total hip replacement (THR) are limited. The aim of this nationwide study was to describe and quantify early morbidity after aseptic revision THR and relate the morbidity to the extent of the revision surgical procedure. We analysed all aseptic revision THRs from 1st October 2009 to 30th September 2011 using the Danish National Patient Registry, with additional information from the Danish Hip Arthroplasty Registry. There were 1553 procedures (1490 patients) performed in 40 centres and we divided them into total revisions, acetabular component revisions, femoral stem revisions and partial revisions. The mean age of the patients was 70.4 years (25 to 98) and the median hospital stay was five days (interquartile range 3 to 7). Within 90 days of surgery, the readmission rate was 18.3%, mortality rate 1.4%, re-operation rate 6.1%, dislocation rate 7.0% and infection rate 3.0%. There were no differences in these outcomes between high- and low-volume centres. Of all readmissions, 255 (63.9%) were due to 'surgical' complications versus 144 (36.1%) 'medical' complications. Importantly, we found no differences in early morbidity across the surgical subgroups, despite major differences in the extent and complexity of operations. However, dislocations and the resulting morbidity represent the major challenge for improvement in aseptic revision THR. Cite this article: Bone Joint J 2014; 96-B:1464-71.
    The bone & joint journal. 11/2014; 96-B(11):1464-71.
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    ABSTRACT: Aim To describe the increased activity in total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2002 to 2012 in a single orthopaedic department, the organisation of fast-track and its consequences for nursing care. Methods Design; retrospective, descriptive. Data collection; from the hospital administrative database, local descriptions of fast-track and personal contact and discussion with staff. Results The number of operations increased threefold from 351 operations in 2002 to 1024 operations in 2012. In 2012, THA/TKA patients had a postoperative mean LOS of 2.6/2.8 days. Nurses had gained tasks from surgeons and physiotherapists and thus gained more responsibility for example within pain management and mobilisation. Staffing levels in the ward in 2002 and 2012 were almost unchanged; 16.0 and 15.8 respectively. Nurses were undertaken more complicated tasks. Conclusion Nursing care must still focus on the individual patient. Nurses need to have enough education to manage the complex tasks and increased responsibility. Furthermore, to prevent undesirable outcomes in the future, there is a need to pay attention to the nursing quality in balance with the nursing budget. It may, therefore, be considered a worthwhile investment to employ expert/highlyqualified professional nurses in fast-track THA and TKA units.
    International Journal of Orthopaedic and Trauma Nursing 10/2014;
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    ABSTRACT: Background and purpose - Postoperative joint stiffness following total knee arthroplasty (TKA) may compromise the outcome and necessitate manipulation. Previous studies have not been in a fast-track setting with optimized pain treatment, early mobilization, and short length of stay (LOS), which may have influenced the prevalence of joint stiffness and subsequent manipulation. We investigated the prevalence of manipulation following fast-track TKA and identified patients at risk of needing manipulation. Patients and methods - 3,145 consecutive unselected elective primary unilateral TKA patients operated in 6 departments with well-defined fast-track settings were included in the study. Demographic data, prevalence, type and timing of manipulation, and preoperative and postoperative ROM were recorded prospectively, ensuring complete 1-year follow-up. Results - 70 manipulations were performed within 1 year (2.2%) at a mean of 4 months after index surgery. Younger age and not using walking aids preoperatively were associated with a higher risk of manipulation. LOS ≤ 4 days (as opposed to a longer LOS) was not associated with an increased risk of manipulation. Interpretation - The prevalence of manipulation was lower or comparable to that in most published studies following more conventional pathways. Inherent patient demographics were identified as risk factors for manipulation whereas LOS ≤ 4 days was not. Thus, fast-track TKA does not result in increased risk of manipulation-despite a shorter LOS. Optimized pain treatment and early mobilization may contribute to these favorable results that support the use of fast-track.
    Acta orthopaedica. 09/2014;
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    ABSTRACT: Retrospective review of prospectively collected data.
    Archives of Orthopaedic and Trauma Surgery 08/2014; · 1.31 Impact Factor
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    ABSTRACT: Triage of patients with ovarian cancer to primary debulking surgery (PDS) or neoadjuvant chemotherapy (NACT) is challenging. In Denmark, the use of NACT has increased, but substantial differences in the use of NACT or PDS exist among centers. We aimed to characterize the differences between intended and actual first-line treatments in addition to the differences in the triage process among the centers and to evaluate the different diagnostic modalities and the clinical aspects' influence in the triage process.
    International Journal of Gynecological Cancer 08/2014; · 1.95 Impact Factor
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    ABSTRACT: Quantitative sensory testing (QST) is used to assess sensory dysfunction and nerve damage by examining psychophysical responses to controlled, graded stimuli such as mechanical- and thermal detection and pain thresholds. In the breast cancer population, 4 studies have used QST to examine persistent pain after breast cancer treatment (PPBCT), suggesting neuropathic pain being a prominent pain mechanism. However, the agreement and reliability of QST has not been described in the postsurgical breast cancer population, hindering exact interpretation of QST studies in this population. The aim of the present study was to assess test-retest properties of QST after breast cancer surgery.
    Clinical Journal of Pain 07/2014; · 2.70 Impact Factor
  • E K Aasvang, M U Werner, H Kehlet
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    ABSTRACT: Deep pain complaints are more frequent than cutaneous in post-surgical patients, and a prevalent finding in quantitative sensory testing studies. However, the preferred assessment method - pressure algometry - is indirect and tissue unspecific, hindering advances in treatment and preventive strategies. Thus, there is a need for development of methods with direct stimulation of suspected hyperalgesic tissues to identify the peripheral origin of nociceptive input.
    Acta Anaesthesiologica Scandinavica 07/2014; · 2.36 Impact Factor
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    ABSTRACT: In Denmark approximately 10 000 groin hernias are repaired annually, of which 2% to 4% are femoral hernias. Several methods for repair of femoral hernias are used including sutured repair and different types of mesh repair with either open or laparoscopic techniques. The use of many different approaches reflects a rather low level of evidence for the best method of repair. Randomized clinical trials are lacking. Large, prospective cohort studies are an alternative way of acquiring improved evidence regarding the best type of repair.
    JAMA surgery. 07/2014; 149(8).
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    ABSTRACT: Background Mesh repair reduces the risk of reoperation for recurrence in patients with primary ventral hernias. However, reoperation for recurrence underestimates total recurrence (reoperation + clinical) and mesh reinforcement may induce chronic pain. This study investigated the total recurrence and risk of chronic pain in small primary ventral hernias. Methods A cohort study with questionnaire and clinical follow-up was conducted. Patients with primary, elective, open mesh or sutured repair for a small umbilical or epigastric hernia (≤2 cm) were included. Results 1 313 patients completed the questionnaire. The total cumulated recurrence rate after primary repair was 10 % for mesh repair and 21 % for sutured repair (P = 0.001). The incidence of chronic pain was 6 % after mesh repair and 5 % after sutured repair (P = 0.711). Conclusions Mesh repair halved long-term risk of recurrence after repair for small ventral hernias without increased risk of chronic pain.
    The American Journal of Surgery 07/2014; · 2.41 Impact Factor
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    ABSTRACT: Objective. To compare 7 weeks of supervised physical rehabilitation with or without progressive strength training (PST) commenced early after fast-track total knee arthroplasty (TKA) on functional performance.Methods. Eighty-two patients with a unilateral primary TKA were randomized to 2 different interventions: 7 weeks of supervised physical rehabilitation with (PST-group) and without (CON-group) PST commenced early after fast-track TKA. The primary outcome was the maximal distance walked in 6 minutes (6-minute walk test). Secondary outcomes were lower limb strength and power, knee joint effusion and range of motion, knee pain and self-reported disability and quality of life. All outcome measures were assessed before (baseline) and 4, 8 and 26 weeks after TKA.Results. There was no statistically significant difference between the PST- and CON-group in the change score from baseline to the 8-week postoperative assessment (primary endpoint) for the 6-minute walk test with unadjusted baseline scores (mean difference between groups: -11.3 meters, 95% confidence interval -45.4 to 22.7 meters; analysis of variance (ANOVA), p=0.51). There were no statistically significant or clinically meaningful differences between groups in change scores from baseline to any other time point for all secondary outcomes. The secondary outcome, knee-extension strength did not reach the level recorded before surgery in both groups.Conclusions. Seven weeks of supervised physical rehabilitation with PST was not superior to 7 weeks of supervised physical rehabilitation without PST in improving functional performance, measured as the maximal walking distance in 6 minutes, at the primary endpoint 8 weeks after fast-track TKA. © 2014 American College of Rheumatology.
    Arthritis Care & Research. 07/2014;

Publication Stats

28k Citations
2,920.31 Total Impact Points

Institutions

  • 2008–2014
    • Copenhagen University Hospital
      København, Capital Region, Denmark
    • Aalborg University Hospital
      • Department of Orthopaedic Surgery
      Aalborg, Region North Jutland, Denmark
    • Glostrup Hospital
      Glostrup, Capital Region, Denmark
  • 1986–2014
    • University of Copenhagen
      • • Surgical Pathophysiology Unit
      • • Department of Surgery
      København, Capital Region, Denmark
  • 2009–2013
    • Køge Sygehus
      Kjoge, Zealand, Denmark
  • 2008–2013
    • Region Hovedstaden
      Hillerød, Capital Region, Denmark
  • 1985–2013
    • Copenhagen University Hospital Hvidovre
      • • Department of Anesthesiology
      • • Department of Gynecology and Obstetrics
      • • Department of Pathology
      Hvidovre, Capital Region, Denmark
  • 2002–2012
    • University of Texas Southwestern Medical Center
      • Department of Anesthesiology and Pain Management
      Dallas, TX, United States
  • 1999–2012
    • Rigshospitalet
      • • Surgical Pathophysiology Unit
      • • Department of Anaesthesiology
      • • Department of Surgical Gastroenterology
      Copenhagen, Capital Region, Denmark
  • 1996–2012
    • IT University of Copenhagen
      København, Capital Region, Denmark
  • 1984–2012
    • Bispebjerg Hospital, Copenhagen University
      • • Department of Surgery
      • • Department of Anesthesiology
      Copenhagen, Capital Region, Denmark
  • 1977–2012
    • Herlev Hospital
      Herlev, Capital Region, Denmark
  • 2007–2011
    • Aarhus University Hospital
      • Department of Anaesthesiology
      Aarhus, Central Jutland, Denmark
    • University of Geneva
      • Division of Anaesthesiology
      Genève, GE, Switzerland
  • 2001–2011
    • Harvard Medical School
      • • Department of Anesthesia
      • • Department of Surgery
      Boston, Massachusetts, United States
    • University of Münster
      Muenster, North Rhine-Westphalia, Germany
  • 2010
    • University of Toronto
      • Division of General Surgery
      Toronto, Ontario, Canada
  • 2003–2010
    • Lund University
      • • Department of Physical Therapy
      • • Department of Health Sciences
      • • Department of Oncology
      Lund, Skane, Sweden
  • 2005–2009
    • Sundhedsstyrelsen
      København, Capital Region, Denmark
    • The University of Edinburgh
      • School of Clinical Sciences and Community Health
      Edinburgh, SCT, United Kingdom
  • 2004–2009
    • Regionspsykiatrien Viborg-Skive
      Viborg, Central Jutland, Denmark
  • 2006
    • Aarhus University
      Aarhus, Central Jutland, Denmark
  • 2000
    • University of Rochester
      • Department of Anesthesiology
      Rochester, NY, United States
  • 1993–1998
    • Aalborg University
      • Department of Health Science and Technology
      Ålborg, North Denmark, Denmark
  • 1992
    • Regional Hospital Silkeborg
      Silkeborg, Central Jutland, Denmark
  • 1990
    • København Zoo
      København, Capital Region, Denmark
  • 1988
    • University of Copenhagen Herlev Hospital
      Herlev, Capital Region, Denmark
  • 1982
    • Roskilde Hospital
      Roskilde, Zealand, Denmark