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Tissue AdhesionPAIN PADNCT03938168

Histological and Molecular Mechanisms of Pain in Patient With Chronic Pain From Adhesions

An observational study of Tissue Adhesion and Chronic Pain, run by Radboud University Medical Center at 3 sites in Netherlands.

Completed

Finished. The study has ended and is not enrolling. Results may be posted on the official record.

Official record
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Trial summary

11-20% of patients undergoing abdominal surgery develop chronic abdominal pain. Adhesions are a common cause of chronic pain following surgery. Adhesions develop after up to 90% of laparotomies and 70% of laparoscopic surgeries. Obviously, not all adhesions cause pain. Read more about this study

Who is it for?
Ages 18 years and older
Conditions the study is for
Tissue Adhesion, Chronic Pain, Surgery
What is being tested?
Biopsy, fecal sample
How many people
61 participants
Where
3 sitesNetherlands
Study dates
9 Apr 2019to 20 Dec 2024
Phase
Observational
Are there results?
None posted in the registry

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

  • Ages 18 years and older
  • All sexes
  • No healthy volunteers
  • Adult, Older adult

Study population: Chronic abdominal pain after surgery is a frequent condition.(13) At present the RadboudUMC, MUMC+, and Pantein hospital departments of surgery annually evaluate 60-80 patients each for chronic pain by cineMRI. Between 30-40 of these patients are expected to undergo surgical treatment. Yearly between 600-700 patients will undergo an elective abdominal reoperation at the participating departments of surgery. Thus there is ample surgical volume for this study.

Who may be able to join

  • Patients between 18 and 75 years old scheduled for elective abdominal reoperation
  • No present chronic abdominal pain
  • No other diseases or syndromes that cause chronic pain (e.g. rheumatic arthritis)

Who cannot join

  • A potential subject with chronic pain will be excluded from participation in this study in the following cases:
  • Contra-indications for general anaesthesia and re-operation
  • Inability to acquire informed consent

Trial locations and contacts

3 sites in 1 country.

Netherlands3 sites
  • Maasziekenhuis Pantein

    Boxmeer, Gelderland, 5830 AB

  • Maastricht Universitair Medisch Centrum+

    Maastricht, Limburg, 6202 AZ

  • Radboud University Medical Center

    Nijmegen, Gelderland, 6500HB

Other trials in Netherlands

About this study

Official title: PAIN PAD Histological and Molecular Mechanisms of Pain in Patient With Chronic Pain From Adhesions

11-20% of patients undergoing abdominal surgery develop chronic abdominal pain. Adhesions are a common cause of chronic pain following surgery. Adhesions develop after up to 90% of laparotomies and 70% of laparoscopic surgeries. Obviously, not all adhesions cause pain. It is still poorly understood why adhesions cause pain in some patients, while other patients with adhesions experience no pain.

In this study we explore possible mechanism through which adhesions might cause pain. For this purpose we will assess expression of molecular mediators (such as TRPV-1, SP, and the neurokinin receptor), histological characteristics, and fecal microbioma that might be associated with pain.Expression of these factor will be compared to sample from 30 patients with chronic pain attributed to adhesions, and 30 patients undergoing a reoperation with adhsiolysis for reasons unrelated to pain.

Read the detailed description

Introduction and rationale:

11-20% of patients undergoing abdominal surgery develop chronic abdominal pain. Adhesions are the most common cause of chronic abdominal complaints after surgery. Chronic pain from adhesions has devastating consequences for quality of life, and one in three patients with pain from adhesions is opioid dependent.

Adhesions develop after up to 90% of laparotomies and 70% of laparoscopic surgeries. Obviously, not all adhesions cause pain. It is still poorly understood why adhesions cause pain in some patients, while other patients with adhesions experience no pain.

In a recent study we demonstrated that in selected patients adhesion-related pain can effectively be treated by operation with adhesiolysis and application of an adhesion barrier. However, almost 50% part of patients with adhesion-related pain are not considered a candidate for surgical treatment, for various reasons.

Exploring the mechanisms that contribute to development of pain in patients with adhesions could provide novel targets for medical therapies. These could greatly benefit many patients suffering from adhesion- related pain. Two factors that might explain why some patients with adhesions develop chronic pain are activation of molecular mechanisms involved in chronic pain and stimulation of nerve fibers present in adhesions. Specifically type C nerve fibres are associated with development of neuropathic pain. Further we will also explore differences in microbioma, which has recently been demonstrated to have an important role in a variety of abdominal conditions.

Adhesion formation at the molecular level involves a complex interaction of mediators. One such mediator that might link adhesion formation to nociception is the pro-inflammatory peptide substance P.(1) Substance P in turn is mediated by Transient Receptor Potential Vanilloid (TRPV1), which is known to be upregulated in many conditions associated with chronic pain. There is currently much research in developing new analgesics targeting this receptor. Previous studies have shown that nerve fibres can be present in adhesive tissue. Presence of such fibres, and especially type C fibres might be responsible for a neuropathic type of pain. Stimulation of TRPV1 might also activate type C nerve fibre endings.

Objective:

Quantify and compare expression of molecular mediators (such as TRPV-1, SP, and the neurokinin receptor) and histological characteristics of adhesions from patients with postoperative adhesions with and without chronic abdominal pain. Comparison of microbioma in fecal samples between patients with adhesions with and without chronic abdominal pain

Study design:

This is a prospective observational cohort study.

Study population:

30 patients eligible for adhesiolysis because of chronic adhesion-related pain. Patients are recruited at the RadboudUMC, MUMC+ and Pantein hospital departments of surgery. These are patients with chronic pain after previous abdominal surgery who have been selected for operative treatment after evaluated with CineMRI. CineMRI is used to map adhesions. This technique has been established to provide insight in localization of adhesions in relation to the pain, and risk of bowel injury based on extensiveness of adhesions. The control group will comprise of 30 patients undergoing an abdominal reoperation during which adhesiolysis has to be performed for reasons other than chronic adhesion-related pain.

Study procedures:

Prior to surgery patients are requested to take a stool sample. During surgery histological samples of adhesions will be taken during adhesiolysis in both groups. In the control group histological samples of adhesions will only be taken if it does not require extension of the incision and if it is not accompanied with additional risk of intraoperative complications other than necessary for their planned surgery.

Main study parameters/endpoints:

Primary outcome mRNA expression levels of TRPV1 by quantitative polymerase chain reaction (qPCR) compared between patients with and without chronic pain. Secondary outcomes are TRPV1 protein levels (measured by Westernblot), SP, and neurokinin expression, and the amount and types of nerve fibres found at histological assessment. Further we will explore microbioma in feca samples.

Nature and extent of the burden and risks associated with participation, benefit and group relatedness:

Taking fecal and histological samples for this study does not result in additional operative risk. Adhesiolysis is often performed during any type of abdominal reoperation. Histological samples in controls are only taken from adhesions that are easily accessible and not from dense adhesions in close proximity to bowel or other vulnerable organs. No additional adhesiolysis apart from biopsy will be performed.

Being tested
Biopsy, fecal sample
Medical subject headings
Tissue Adhesions, Chronic Pain

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

  • Biopsy, fecal sampleDiagnostic test

    Preoperatively and at 12 months after surgery, patients will obtain a fecal stool sample for microbioma analysis. Adhesions that are cut and released to acquire access to the operative field are stored for molecular and histological analyses.

Study groups in NCT03938168
Study groupRoleWhat they receive
Pain patients30 patients eligible for adhesiolysis because of chronic adhesion-related pain. Patients are recruited at the RadboudUMC, MUMC+ and Pantein hospital departments of surgery. These are patients with chronic pain after previous abdominal surgery who have been selected for operative treatment after evaluated with CineMRI. CineMRI is used to map adhesions. This technique has been established to provide insight in localization of adhesions in relation to the pain, and risk of bowel injury based on extensiveness of adhesions.
Receives: Diagnostic Test: Biopsy, fecal sample
Control groupThe control group will comprise of 30 patients undergoing an abdominal reoperation during which adhesiolysis has to be performed for reasons other than chronic adhesion-related pain.
Receives: Diagnostic Test: Biopsy, fecal sample

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. TRPV-1

    mRNA expression levels of TRPV1 by quantitative polymerase chain reaction (qPCR)

    Measured: during surgery

Secondary outcomes (5)
  1. TRPV-1 protein

    TRPV1 protein levels (measured by Westernblot)

    Measured: during surgery

  2. SP

    mRNA expression levels of Substance P

    Measured: during surgery

  3. NK-1

    mRNA expression levels of Neurokinin 1

    Measured: during surgery

  4. Nerve fibers

    Histological assessment for the presence of nerve fibers

    Measured: during surgery

  5. Microbioma

    alpha and beta diversity of Fecal microbioma pre-operative and at 12 months after surgery

    Measured: 12 months

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted6 May 2019
  2. Study start9 Apr 2019
  3. Primary completion31 Dec 2023
  4. Study completion20 Dec 2024

Resources

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design
Study type
Observational
Observational model
Cohort
Time perspective
Prospective
Enrolment
61 participants (actual)
IDs, dates and publications
ClinicalTrials.gov ID
NCT03938168
Sponsor's protocol ID
2018-4801
Acronym
PAIN PAD
Status last verified
Dec 2024
First submitted
1 May 2019
Last updated
31 Dec 2024
Results posted
No
Data monitoring committee
No
FDA-regulated drug
No
FDA-regulated device
No
Individual data sharing
Yes: IPD will be shared upon reasonable request through DANS easy archive

Publications

  • van den Beukel BAW, Stommel MWJ, van Leuven S, Strik C, IJsseldijk MA, Joosten F, van Goor H, Ten Broek RPG. A Shared Decision Approach to Chronic Abdominal Pain Based on Cine-MRI: A Prospective Cohort Study. Am J Gastroenterol. 2018 Aug;113(8):1229-1237. doi: 10.1038/s41395-018-0158-9. Epub 2018 Jun 27.

    PubMed 29946174
  • Reed KL, Fruin AB, Bishop-Bartolomei KK, Gower AC, Nicolaou M, Stucchi AF, Leeman SE, Becker JM. Neurokinin-1 receptor and substance P messenger RNA levels increase during intraabdominal adhesion formation. J Surg Res. 2002 Nov;108(1):165-72. doi: 10.1006/jsre.2002.6533.

    PubMed 12443729
  • ten Broek RP, Issa Y, van Santbrink EJ, Bouvy ND, Kruitwagen RF, Jeekel J, Bakkum EA, Rovers MM, van Goor H. Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ. 2013 Oct 3;347:f5588. doi: 10.1136/bmj.f5588.

    PubMed 24092941
  • Keszthelyi D, Troost FJ, Jonkers DM, Helyes Z, Hamer HM, Ludidi S, Vanhoutvin S, Venema K, Dekker J, Szolcsanyi J, Masclee AA. Alterations in mucosal neuropeptides in patients with irritable bowel syndrome and ulcerative colitis in remission: a role in pain symptom generation? Eur J Pain. 2013 Oct;17(9):1299-306. doi: 10.1002/j.1532-2149.2013.00309.x. Epub 2013 Mar 25.

    PubMed 23529955
  • Scotland RS, Chauhan S, Davis C, De Felipe C, Hunt S, Kabir J, Kotsonis P, Oh U, Ahluwalia A. Vanilloid receptor TRPV1, sensory C-fibers, and vascular autoregulation: a novel mechanism involved in myogenic constriction. Circ Res. 2004 Nov 12;95(10):1027-34. doi: 10.1161/01.RES.0000148633.93110.24. Epub 2004 Oct 21.

    PubMed 15499026

Questions about this trial

What is this clinical trial studying?

An observational study of Tissue Adhesion and Chronic Pain, run by Radboud University Medical Center at 3 sites in Netherlands.

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 3 inclusion and 3 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: finished, as of the sponsor's last update on 31 Dec 2024. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 3 sites in Netherlands. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

Are results available for this study?

The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.

How can a doctor refer a patient or contact the research team?

The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

TRPV-1 (time frame: during surgery). It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT03938168, which also lists 5 linked publications.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 31 Dec 2024.

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