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Yue C, Wei R, Liu Y. Perioperative systemic steroid for rapid recovery in total knee and hip arthroplasty: a systematic review and meta-analysis of randomized trials. J Orthop Surg Res 2017; 12:100. [PMID: 28655354 PMCID: PMC5488481 DOI: 10.1186/s13018-017-0601-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 06/20/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Perioperative systemic steroid administration for rapid recovery in total knee and hip arthroplasty (TKA/THA) is an important and controversial topic. We conducted this systematic review and meta-analysis to evaluate the overall benefits and harms of perioperative systemic steroid in patients undergoing TKA and THA. METHODS A comprehensive search was performed on PubMed, OVID, and Web of Science databases, and a systematic approach was carried out starting from the PRISMA recommendations. Relevant randomized controlled trials (RCTs) were selected. The risk of bias was evaluated according to the Cochrane Handbook for Systematic Reviews of Interventions version. Data were extracted and meta-analyzed or qualitatively synthesized for all the outcomes. RESULTS Data were extracted from 11 trials involving 774 procedures. Meta-analysis showed that high-dose systemic steroid (dexamethasone > 0.1 mg/kg) rather than low dose is effective to reduce postoperative nausea and vomiting and postoperative acute pain (within 24 h). In addition, systemic steroid is associated within faster functional rehabilitation and greater inflammation control. On the other hand, systemic steroid is associated with a higher level of postoperative serum glucose on the operation day. The complications between groups are similarly low. CONCLUSIONS Our study suggests that by providing lower incidence of postoperative nausea and vomiting and less postoperative acute pain, high-dose systemic steroid plays a critical role in rapid recovery to TKA and THA. The preliminary results also show the superior possibility of systemic steroid in functional rehabilitation and inflammation control. More large, high-quality studies that investigate the safety and dose-response relationship are necessary.
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Affiliation(s)
- Chen Yue
- Department of Orthopedic Surgery, Luoyang Orthopedic Hospital of Henan Province. Orthopedic Hospital of Henan Province, 82# QiMing Road, 471000, Luoyang, Henan Province, China
| | - Rong Wei
- Department of Orthopedic Surgery, Luoyang Central Hospital Affiliated to Zhengzhou University, 471000, Luoyang, Henan Province, China
| | - Youwen Liu
- Department of Orthopedic Surgery, Luoyang Orthopedic Hospital of Henan Province. Orthopedic Hospital of Henan Province, 82# QiMing Road, 471000, Luoyang, Henan Province, China.
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McSorley ST, Roxburgh CSD, Horgan PG, McMillan DC. The Impact of Preoperative Dexamethasone on the Magnitude of the Postoperative Systemic Inflammatory Response and Complications Following Surgery for Colorectal Cancer. Ann Surg Oncol 2017; 24:2104-2112. [PMID: 28251379 PMCID: PMC5491680 DOI: 10.1245/s10434-017-5817-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The magnitude of the postoperative systemic inflammatory response (SIR), as evidenced by C-reactive protein (CRP), is associated with both short- and long-term outcomes following surgery for colorectal cancer. The present study examined the impact of preoperative dexamethasone on the postoperative SIR and complications following elective surgery for colorectal cancer. METHODS Patients who underwent elective surgery, with curative intent, for colorectal cancer at a single center between 2008 and 2016 were included (n = 556) in this study. Data on the use of preoperative dexamethasone were obtained from anesthetic records, and its impact on CRP on postoperative days (PODs) 3 and 4, as well as postoperative complications, was assessed using propensity score matching (n = 276). RESULTS In the propensity score-matched cohort, preoperative dexamethasone was associated with fewer patients exceeding the established CRP threshold of 150 mg/L on POD 3 (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26-0.70, p < 0.001) and fewer postoperative complications (OR 0.53, 95% CI 0.33-0.86, p = 0.009). Similar results for both POD 3 CRP and complications were observed when using propensity score-adjusted regression (OR 0.40, 95% CI 0.28-0.57 and OR 0.57, 95% CI 0.41-0.80, respectively) and propensity score stratification (OR 0.41, 95% CI 0.25-0.57 and OR 0.53, 95% CI 0.33-0.86, respectively). CONCLUSIONS Preoperative dexamethasone was associated with a lower postoperative SIR and fewer complications following elective surgery for colorectal cancer.
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Affiliation(s)
- Stephen T McSorley
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow, Scotland, UK.
| | - Campbell S D Roxburgh
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow, Scotland, UK
| | - Paul G Horgan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow, Scotland, UK
| | - Donald C McMillan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow, Scotland, UK
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Abstract
Abstract
Background
Glucocorticoids are increasingly used perioperatively, principally to prevent nausea and vomiting. Safety concerns focus on the potential for hyperglycemia and increased infection. The authors hypothesized that glucocorticoids predispose to such adverse outcomes in a dose-dependent fashion after elective noncardiac surgery.
Methods
The authors conducted a systematic literature search of the major medical databases from their inception to April 2016. Randomized glucocorticoid trials in adults specifically reporting on a safety outcome were included and meta-analyzed with Peto odds ratio method or the quality effects model. Subanalyses were performed according to a dexamethasone dose equivalent of low (less than 8 mg), medium (8 to 16 mg), and high (more than 16 mg). The primary endpoints of any wound infection and peak perioperative glucose concentrations were subject to meta-regression.
Results
Fifty-six trials from 18 countries were identified, predominantly assessing dexamethasone. Glucocorticoids did not impact on any wound infection (odds ratio, 0.8; 95% CI, 0.6 to 1.2) but did result in a clinically unimportant increase in peak perioperative glucose concentration (weighted mean difference, 20.0 mg/dl; CI, 11.4 to 28.6; P < 0.001 or 1.1 mM; CI, 0.6 to 1.6). Glucocorticoids reduced peak postoperative C-reactive protein concentrations (weighted mean difference, −22.1 mg/l; CI, −31.7 to −12.5; P < 0.001), but other adverse outcomes and length of stay were unchanged. No dose–effect relationships were apparent.
Conclusions
The evidence at present does not highlight any safety concerns with respect to the use of perioperative glucocorticoids and subsequent infection, hyperglycemia, or other adverse outcomes. Nevertheless, collated trials lacked sufficient surveillance and power to detect clinically important differences in complications such as wound infection.
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Preoperative High Dose of Methylprednisolone Improves Early Postoperative Pulmonary Function, in Super-Obese Patients Undergoing Open Surgery; a Prospective, Comparative Study. J Gastrointest Surg 2016; 20:1959-1965. [PMID: 27730405 DOI: 10.1007/s11605-016-3281-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 09/13/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgery stimulates an intense systemic inflammatory response which might increase postoperative morbidity. Corticosteroids may reduce this inflammatory reaction. The purpose of this study was to investigate any possible effect on postoperative morbidity and recovery after administrating methylprednisolone in super-obese patients undergoing open surgery. METHODS Sixty super-obese patients with BMI ≥50 kg/m2 (mean 57.48 ± 7.33), mean age of 39 ± 9 years, who underwent an open bariatric procedure, were enrolled. Thirty patients (group A) were allocated to a preoperative single dose of 30 mg/kg (ideal body weight) methylprednisolone versus placebo (group B, 30 patients). Endpoints included assessment of IL-6 and CRP; evaluation of postoperative pulmonary function, pain management, nausea, and vomiting; and documentation of postoperative complications. RESULTS Significant improvement in spirometry parameters and arterial blood gas analysis, in the first and third postoperative days, was observed in the methylprednisolone group. IL-6 and CRP levels were significantly lower in that group. Administration of methylprednisolone was associated with less postoperative pain, nausea, and vomiting, with no statistical difference in septic complications. CONCLUSIONS Preoperative administration of a single high dose of methylprednisolone in super-obese patients undergoing open surgery inhibits the inflammatory signaling cascade, lessens the systemic inflammatory response, and results in fewer pulmonary complications and better patient recovery.
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Luigi De M, Brice P, David O, Olivier F, Giovanni di G, Patrick R, Christine B, Pablo OD. Preoperative inflammation increases the risk of infection after elective colorectal surgery: results from a prospective cohort. Int J Colorectal Dis 2016; 31:1611-7. [PMID: 27357511 PMCID: PMC5517619 DOI: 10.1007/s00384-016-2620-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Septic complications after colorectal surgery are frequent and sometimes life threatening. It is well known that inflammation impairs the healing process. It has been suggested that preoperative ongoing inflammation could increase the risk of postoperative infections. This study aimed to elucidate the role of preoperative inflammation on postoperative infectious complications and to understand if, through biological markers, it is possible to identify preoperatively patients at higher risk of infection. METHODS A prospective, observational study was conducted in three centers from November 2011 to April 2014. Consecutive patients undergoing elective colorectal surgery with anastomosis were included. Any ongoing infection was an exclusion criterion. C-reactive protein, albumin, prealbumin, and procalcitonin plasma levels were measured preoperatively. Postoperative infections were recorded according to the definitions of the Centers for Diseases Control. The areas under the receiver operating characteristic curve were analyzed and compared to assess the accuracy of each preoperative marker. RESULTS Four-hundred and seventy two patients were analyzed. Infectious complications occurred in 118 patients (25 %) and mortality in 6 patients (1.3 %). In the univariate analysis, preoperative C-reactive protein and albuminemia were found significantly associated with postoperative infectious complications (P = 0.008 and P = 0.0002, respectively). Areas under the ROC curve for preoperative C-reactive protein and albuminemia were 0.57and 0.62, respectively. CONCLUSIONS This study confirms the association between preoperative inflammatory activity, hypoalbuminemia, and the onset of infections after surgery. Trials aiming to decrease the inflammatory activity before surgery in order to prevent postoperative complications are warranted.
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Affiliation(s)
- Magistris Luigi De
- Service de Chirurgie Digestive, Cancérologique, Générale, Endocrinienne et Urgences (CHU de Dijon)
Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - CHU Dijon - 14 rue Paul Gaffarel - 21079 Dijon
| | - Paquette Brice
- Service de Chirurgie Digestive [CHU Besançon]
Centre Hospitalier Régional Universitaire [Besançon] - Université de Franche-Comté - Place Saint Jacques 25000 Besançon
| | - Orry David
- CRLCC - CGFL, Centre Régional de Lutte Contre le Cancer - Centre Georges-François Leclerc
1 rue du Professeur Marion, 21000 Dijon
| | - Facy Olivier
- Service de Chirurgie Digestive, Cancérologique, Générale, Endocrinienne et Urgences (CHU de Dijon)
Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - CHU Dijon - 14 rue Paul Gaffarel - 21079 Dijon,Chimiothérapie et Réponse Immunitaire Anti-Tumorale (U866, Cancer, équipe 1)
Université de Bourgogne - Institut National de la Santé et de la Recherche Médicale - U866Université de Bourgogne - 21000 Dijon
| | - Giacomo Giovanni di
- Service de Chirurgie Digestive, Cancérologique, Générale, Endocrinienne et Urgences (CHU de Dijon)
Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - CHU Dijon - 14 rue Paul Gaffarel - 21079 Dijon
| | - Rat Patrick
- Service de Chirurgie Digestive, Cancérologique, Générale, Endocrinienne et Urgences (CHU de Dijon)
Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - CHU Dijon - 14 rue Paul Gaffarel - 21079 Dijon,Chimiothérapie et Réponse Immunitaire Anti-Tumorale (U866, Cancer, équipe 1)
Université de Bourgogne - Institut National de la Santé et de la Recherche Médicale - U866Université de Bourgogne - 21000 Dijon
| | - Binquet Christine
- Chimiothérapie et Réponse Immunitaire Anti-Tumorale (U866, Cancer, équipe 1)
Université de Bourgogne - Institut National de la Santé et de la Recherche Médicale - U866Université de Bourgogne - 21000 Dijon,CIC-EC, Centre d'Investigation Clinique 1432 (Dijon) - Epidemiologie Clinique/Essais Cliniques
Université de Bourgogne - Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - Institut National de la Santé et de la Recherche Médicale - Faculté de MédecineBP 87900 - 7 boulvard Jeanne d'Arc - 21079 Dijon Cedex
| | - Ortega-Deballon Pablo
- Service de Chirurgie Digestive, Cancérologique, Générale, Endocrinienne et Urgences (CHU de Dijon)
Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - CHU Dijon - 14 rue Paul Gaffarel - 21079 Dijon,Chimiothérapie et Réponse Immunitaire Anti-Tumorale (U866, Cancer, équipe 1)
Université de Bourgogne - Institut National de la Santé et de la Recherche Médicale - U866Université de Bourgogne - 21000 Dijon,* Correspondence should be addressed to Ortega-Deballon Pablo
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McSorley ST, Watt DG, Horgan PG, McMillan DC. Postoperative Systemic Inflammatory Response, Complication Severity, and Survival Following Surgery for Colorectal Cancer. Ann Surg Oncol 2016; 23:2832-40. [PMID: 27016295 PMCID: PMC4972846 DOI: 10.1245/s10434-016-5204-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study examined the relationship between the magnitude of the postoperative systemic inflammatory response (SIR), the severity of complications, and long-term outcomes following surgery for colorectal cancer. METHODS Data were recorded prospectively for patients undergoing potentially curative surgery for colorectal cancer in a single centre between 2008 and 2013. The magnitude of the SIR was measured using C-reactive protein (CRP). Complications were classified by Clavien-Dindo grade. The impact on disease specific and overall survival was assessed using univariate and multivariate Cox regression. RESULTS Of 377 patients included, the majority were male (55 %), older than age 65 years (68 %), with colonic (63 %) and node-negative disease (66 %). A total of 138 patients (37 %) had a complication, of which 26 (6 %) were Clavien-Dindo grade 3 or 4 severity. Complication severity was significantly associated with the established CRP thresholds of 150 mg/L on postoperative day (POD) 3 (p < 0.001) and POD 4 (p < 0.001). Median follow-up was 42 months with disease-specific survival 86 % and overall survival 78 %. On univariate analysis, complication severity [hazard ratio (HR) 1.66, 95 % confidence interval (CI) 1.13-2.43, p = 0.009], and POD 4 CRP > 150 mg/L (HR 2.53, 95 % CI 1.43-4.48, p = 0.001) were associated with disease-specific survival. On multivariate survival analysis, POD 4 CRP > 150 mg/L (HR 2.00, 95 % CI 1.12-3.59, p = 0.020), but not complication severity, was significantly associated with disease-specific survival independent of TNM stage (HR 2.46, 95 % CI 1.52-4.12, p < 0.001). CONCLUSIONS The magnitude of the postoperative SIR, evidenced by CRP, was significantly associated with long-term outcomes following surgery for colorectal cancer, independent of complications and stage.
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Affiliation(s)
- Stephen T McSorley
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK.
| | - David G Watt
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Paul G Horgan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Donald C McMillan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
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Impact of Preemptive Analgesia on inflammatory responses and Rehabilitation after Primary Total Knee Arthroplasty: A Controlled Clinical Study. Sci Rep 2016; 6:30354. [PMID: 27578313 PMCID: PMC5005994 DOI: 10.1038/srep30354] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/20/2016] [Indexed: 11/08/2022] Open
Abstract
The aim of this study was to investigate the effects of preemptive analgesia on the inflammatory response and rehabilitation in TKA. 75 patients with unilateral primary knee osteoarthritis were conducted in this prospective study. All patients were randomly divided into two groups (MMA with/without preemptive analgesia group). The following parameters were used to evaluate analgesic efficacy: knee flexion, pain at rest and walking, functional walking capacity (2 MWT and 6 MWT), WOMAC score, and hs-CRP level. Patients in MMA with preemptive analgesia group had lower hs-CRP level and less pain at rest and walking during the first week postoperatively (P < 0.05). The 2 MWT was significantly better in MMA with preemptive analgesia group (17.13 ± 3.82 VS 14.19 ± 3.56, P = 0.001). The 6 MWT scores and WOMAC scores increased significantly within Groups (P = 0.020, 0.000), but no difference between groups postoperatively (P > 0.05). Less cumulative consumption of morphine was found in MMA with preemptive analgesia group at 48 h (P = 0.017, 0.023), but no difference at total requirement (P = 0.113). Preemptive analgesia added to a multimodal analgesic regime improved analgesia, reduced inflammatory reaction and accelerated functional recovery at the first week postoperatively, but not improved long-term function.
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Steroids Do Not Reduce Persistent Pain after Cardiac Surgery: Should This Be the End of the Question or the Beginning of Newer Questions? Anesthesiology 2016; 125:423-5. [PMID: 27433757 DOI: 10.1097/aln.0000000000001183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Casans Francés R, Ripollés Melchor J, Abad-Gurumeta A, Longás Valién J, Calvo Vecino JM. The role of the anaesthesiologist in enhanced recovery programs. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:273-288. [PMID: 26775121 DOI: 10.1016/j.redar.2015.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 11/04/2015] [Accepted: 11/09/2015] [Indexed: 06/05/2023]
Affiliation(s)
- R Casans Francés
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España.
| | - J Ripollés Melchor
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario «Infanta Leonor», Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - A Abad-Gurumeta
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario La Paz, Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - J Longás Valién
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
| | - J M Calvo Vecino
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario «Infanta Leonor», Madrid, España; Grupo Español de Rehabilitación Multimodal (GERM/ERAS-Spain), España
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Wu M, Zhang L, Bao J, Zhao Z, Lu Q, Feng R, Song C, Zhou J, Jing Z. Postoperative glucocorticoid enhances recovery after endovascular aortic repair for chronic type B aortic dissection: a single-center experience. BMC Cardiovasc Disord 2016; 16:59. [PMID: 27013022 PMCID: PMC4807598 DOI: 10.1186/s12872-016-0234-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 03/19/2016] [Indexed: 12/27/2022] Open
Abstract
Background Thoracic endovascular aortic repair (TEVAR) has been chosen as a less invasive alternative for type B aortic dissections (TBADs). However, the therapeutic effect of TEVAR has been challenged by postoperative adverse events, which were induced by inflammatory response. Glucocorticoids have been widely used because of the powerful and effective anti-inflammatory properties. Nevertheless, the prognostic effect of glucocorticoids after TBAD patients underwent TEVAR remains unclear. The objective of this study was to assess the potential effect of postoperative glucocorticoids on the prognosis of TEVAR for TBADs. Methods A total of 92 chronic TBADs patients underwent TEVAR with epidural anesthesia between June 2012 and June 2014 was retrospectively reviewed. The patients were stratified into dexamethasone (DXM) and non-dexamethasone group (N-DXM). The indications for TEVAR were as following: malperfusion (n = 28); contained or impending rupture (n = 17); persistent intractable chest/back pain (n = 32); refractory hypertension (n = 15). Results No 30-day mortality and incision infection occurred in each group. The postoperative pain score on the second day was significantly higher in N-DXM group (3.60 ± 0.21 versus 4.83 ± 0.32, P = 0.001). The differences of white blood cell, body temperature and heart rate were pronounced in both groups judged by the peak values (13.01 ± 0.58 × 109/L versus 10.04 ± 0.61 × 109/L, 37.67 ± 0.08 °C versus 37.92 ± 0.09 °C and 89.06 ± 1.21 bpm versus 95.95 ± 1.70 bpm, P = 0.002, 0.04 and 0.001, respectively). The white blood cells in DXM group significantly increased on the second and third postoperative day (P = 0.009 and 0.023), while the body temperature and heart rate showed an apparent decline on the second (P = 0.001 and 0.028), third (P = 0.007 and 0.005) and fourth postoperative days (P = 0.024 and 0.018). However, the changes of false lumen volumes and the endoleak incidence at 3-month follow-up were comparable in the two groups. No significant difference of post-implantation syndrome was observed either. Conclusions Although postoperative prophylactic glucocorticoids administration was unable to influence mortality, incision infection or the change of false lumen volumes, it enabled to enhance the recovery of vital signs and alleviate the postoperative pain. A prospective, randomized controlled trial has been registered (NCT02523300), which will be warranted before prophylactic administration of glucocorticoids after TEVAR procedure could be recommended in the clinical work. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0234-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mengtao Wu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.,Department of Vascular Surgery, General Hospital of Jinan Military Command of Chinese PLA, Jinan, China
| | - Lei Zhang
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Junmin Bao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Qingsheng Lu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Rui Feng
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Chao Song
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Jian Zhou
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
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The impact of preoperative corticosteroids on the systemic inflammatory response and postoperative complications following surgery for gastrointestinal cancer: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2016; 101:139-50. [PMID: 26997303 DOI: 10.1016/j.critrevonc.2016.03.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 02/10/2016] [Accepted: 03/08/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND This meta-analysis examined the impact of preoperative corticosteroids on interleukin 6 (IL-6), C-reactive protein (CRP), and complications following surgery for gastrointestinal cancer. METHODS A systematic review was performed using appropriate keywords. Random-effects meta-analysis was performed. RESULTS 11 RCTs with 474 patients, were included. Corticosteroids were significantly associated with lower IL-6 on postoperative day 1 (mean difference -148pg/mL, 95% CI -205 to -92, p<0.001), 2 (-33pg/mL, 95% CI -58 to -8, p=0.01), and 3 (-31pg/mL, 95% CI -52 to -11, p=0.002), lower CRP on day 3 (-45mg/L, 95% CI -68 to -21, p<0.001), and 7 (-14mg/L, 95% CI -27 to -1, p=0.04), and fewer postoperative infective complications (OR 0.47, 95% CI 0.26-0.83, p=0.01). CONCLUSION Corticosteroids were associated with reduction in the postoperative systemic inflammatory response and complications following surgery for gastrointestinal cancer.
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Ishida K, Shibanuma N, Matsumoto T, Tei K, Kuroda R, Kurosaka M. Periarticular multimodal drug injection improves post-operative pain and functional recovery after total knee arthroplasty. J Orthop Sci 2016; 21:178-83. [PMID: 26723225 DOI: 10.1016/j.jos.2015.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 10/10/2015] [Accepted: 10/31/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND This study retrospectively compared the clinical benefits of periarticular multimodal drug injection (PMDI) and continuous femoral nerve block (CFNB) after total knee arthroplasty (TKA). METHODS From 2010 to 2012, 520 primary TKAs were performed, and patients were treated with CFNB or PMDI after surgery. Patients who underwent simultaneous bilateral TKA were excluded, leaving 185 and 166 patients in the CFNB and PMDI groups, respectively. Numeric rating scale for pain (NRS) scores and analgesic consumption were evaluated to compare the effectiveness of pain control between the groups. Further, range of motion (ROM), extension lag, the time to recovery of functions, and postoperative C-reactive protein (CRP) levels were monitored. Complications such as deep infection were assessed. RESULTS The PMDI group displayed a significantly smaller NRS score on postoperative day (POD) 1 and lower analgesic consumption on PODs 0 and 1. The times to functional recovery were significantly shorter and the extension lag was smaller in the PMDI group. Furthermore, CRP levels were lower in the PMDI group by POD 7. No obvious deep infections were noted. CONCLUSION Our results indicate that PMDI induced earlier functional recovery after TKA than CFNB, partially via its analgesic effect.
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Affiliation(s)
- Kazunari Ishida
- Department of Orthopaedic Surgery, Kobe Kaisei Hospital, 3-11-15, Shinohara-Kita, Nada, Kobe 657-0068, Japan.
| | - Nao Shibanuma
- Department of Orthopaedic Surgery, Kobe Kaisei Hospital, 3-11-15, Shinohara-Kita, Nada, Kobe 657-0068, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Katsumasa Tei
- Department of Orthopaedic Surgery, Chibune General Hospital, Osaka, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Kurosaka
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Jensen KK, Brondum TL, Harling H, Kehlet H, Jorgensen LN. Enhanced recovery after giant ventral hernia repair. Hernia 2016; 20:249-56. [PMID: 26910800 DOI: 10.1007/s10029-016-1471-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/05/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Giant ventral hernia repair is associated with a high risk of postoperative morbidity and prolonged length of stay (LOS). Enhanced recovery (ERAS) measures have proved to lead to decreased morbidity and LOS after various surgical procedures, but never after giant hernia repair. The current study prospectively examined the results of implementation of an ERAS pathway including high-dose preoperative glucocorticoid, and compared the outcome with patients previously treated according to standard care (SC). METHODS Consecutive patients who underwent giant ventral hernia repair were included. Pain, nausea and fatigue were registered prospectively in all patients treated according to ERAS, as well as continuous measurement of transcutaneous capillary oxygen saturation. Postoperative morbidity and LOS were compared between patients treated according to ERAS and a historic group treated with SC. RESULTS A total of 32 patients were included. Postoperative LOS was decreased after the introduction of the ERAS pathway compared with SC (median 3.0 vs. 5.5 days, P = 0.003). Scores of pain, nausea and fatigue were low, while mean oxygen saturation during the first three postoperative days was 0.92. There were no differences when comparing readmission (5 vs. 2, P = 0.394), postoperative complications (7 vs. 4, P = 0. 458), or reoperation (5 vs. 1, P = 0.172) in ERAS versus controls. CONCLUSIONS The current study suggests that an ERAS pathway including preoperative high-dose glucocorticoid may lead to low scores of pain, fatigue and nausea after giant ventral hernia repair with reduced LOS compared with patients treated according to SC.
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Affiliation(s)
- K K Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark.
| | - T L Brondum
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - H Harling
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - H Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - L N Jorgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
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Current strategies for preoperative conditioning of the liver to expand criteria for resectability of hepatic metastases. Eur Surg 2016. [DOI: 10.1007/s10353-015-0381-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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65
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de la Motte L, Schroeder TV, Kehlet H. Should Steroids Be Used During Endovascular Aortic Repair? Adv Surg 2015; 49:173-84. [PMID: 26299498 DOI: 10.1016/j.yasu.2015.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Louise de la Motte
- Department of Vascular Surgery 3111, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark.
| | - Torben V Schroeder
- Center for Clinical Education 5404, Rigshospitalet, University of Copenhagen, Capital Region of Denmark, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology 4074, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
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Qvamme G, Axelsson CK, Lanng C, Mortensen M, Wegeberg B, Okholm M, Arpi MR, Szecsi PB. Randomized clinical trial of prevention of seroma formation after mastectomy by local methylprednisolone injection. Br J Surg 2015; 102:1195-203. [DOI: 10.1002/bjs.9874] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/18/2014] [Accepted: 05/15/2015] [Indexed: 02/05/2023]
Abstract
Abstract
Background
Seroma formation, the most prevalent postoperative complication after mastectomy, is an inflammatory process that is potentially preventable via local steroid administration. This study investigated the effect of local steroid administration on seroma formation.
Methods
This was a double-blind randomized placebo-controlled intervention study of a single dose of 80 mg methylprednisolone versus saline on seroma formation after mastectomy. Patients were further classified according to the surgical axillary procedure: mastectomy with sentinel lymph node biopsy (M + SLNB) or mastectomy with level I–II axillary lymph node dissection (M + ALND). Treatments were administered into the wound cavity via the drain orifice following removal of the drain on the first day after surgery. The primary endpoint was seroma formation; secondary endpoints included the frequency of side-effects and complications.
Results
A total of 212 women scheduled for mastectomy for primary breast cancer were included. After M + SLNB, 32 (46 per cent) of 69 women developed a seroma in the methylprednisolone group, compared with 52 (78 per cent) of 67 in the saline group (P < 0·001). The mean cumulative seroma volume in the intention-to-treat population for the first 10 and 30 days was significantly lower in the methylprednisolone group (24 ml versus 127 ml in the saline group, and 177 versus 328 ml respectively) (P < 0·001). After M + ALND, similar proportions of patients developed a seroma in the methylprednisolone (35 of 37, 95 per cent) and saline (34 of 36, 94 per cent) groups, and methylprednisolone administration had no significant effect on seroma formation. No differences in infection rate were observed.
Conclusion
Methylprednisolone administered into the wound cavity on the first day after M + SLNB exerted a highly significant preventive effect against seroma formation during the next 30 days. This effect was not seen in the M + ALND group. Future studies may clarify whether higher or repeated methylprednisolone doses increase the efficacy.
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Affiliation(s)
- G Qvamme
- Department of Breast Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - C K Axelsson
- Department of Breast Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - C Lanng
- Department of Breast Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - M Mortensen
- Department of Breast Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - B Wegeberg
- Department of Breast Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - M Okholm
- Department of Breast Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - M R Arpi
- Department of Clinical Microbiology, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - P B Szecsi
- Department of Clinical Biochemistry, Copenhagen University Hospital Gentofte, Hellerup, Denmark
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Abstract
Optimal analgesia is a key element of enhanced recovery after surgery (ERAS), not only for humanitarian reasons but also because poorly relieved surgical pain contributes to surgical stress and impairs recovery. A multimodal analgesic approach is advised in order to provide adequate analgesia, reduce opioid consumption, reduce side effects and facilitate the achievement of ERAS milestones. For open surgery, a thoracic epidural for 48 to 72 hours, with regular acetaminophen and antiinflammatories is probably the treatment of choice. For laparoscopic surgery, intrathecal or local anesthesia in the wound combined with regular acetaminophen and antiinflammatory drugs is effective.
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Affiliation(s)
- William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK; Faculty of Health and Medical Sciences, Duke of Kent Building, University of Surrey, Guildford GU2 7TE, UK.
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, 1650 Avenue Cedar, Montreal, Quebec H3G 1A4, Canada
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Preoperative methylprednisolone enhances recovery after endovascular aortic repair: a randomized, double-blind, placebo-controlled clinical trial. Ann Surg 2015; 260:540-8; discussion 548-9. [PMID: 25115430 DOI: 10.1097/sla.0000000000000895] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate effects of preoperative high-dose glucocorticoid on the inflammatory response and recovery after endovascular aortic aneurysm repair (EVAR). BACKGROUND The postimplantation syndrome after EVAR may delay recovery due to the release of proinflammatory mediators. Glucocorticoids may reduce postoperative inflammatory responses and enhance recovery, but with limited information on EVAR. METHODS A single-center, randomized, double-blind, placebo-controlled trial of 153 patients undergoing elective EVAR between November 2009 and January 2013. Patients received 30 mg/kg of methylprednisolone (MP) (n = 77) or placebo (n = 76) preoperatively. Primary outcome was a modified version of the systemic inflammatory response syndrome. Secondary outcome measures were the effect on inflammatory biomarkers, morbidity, and time to meet discharge criteria. RESULTS Of 153 randomized patients, 150 (98%) were evaluated for the primary outcome. MP reduced systemic inflammatory response syndrome from 92% to 27% (P < 0.0001) (number needed to treat = 1.5), maximal plasma interleukin 6 from 186 pg/mL [interquartile range (IQR) = 113-261 pg/mL] to 20 pg/mL (IQR = 11-28 pg/mL) (P < 0.001) and fulfillment of discharge criteria was shorter [2 days (IQR = 2-4 days) vs 3 days (IQR = 3-4 days)] (P < 0.001). C-reactive protein, temperature, interleukin 8, and soluble tumor necrosis factor receptor were also reduced (P < 0.001) by MP. Myeloperoxidase, D-dimer, and matrix metalloproteinase 9 were not modified. No differences in 30-day medical (23% vs 36%) (P = 0.1) or surgical (20% vs 21%) morbidity were found in the active group versus the placebo group. CONCLUSIONS Preoperative MP attenuates the inflammatory response with a faster recovery after EVAR for abdominal aortic aneurysms. Further safety and dose-response studies are required to allow recommendations for general practice. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00989729.
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Vather R, O'Grady G, Bissett IP, Dinning PG. Postoperative ileus: mechanisms and future directions for research. Clin Exp Pharmacol Physiol 2014; 41:358-70. [PMID: 24754527 DOI: 10.1111/1440-1681.12220] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 02/13/2014] [Accepted: 02/25/2014] [Indexed: 12/13/2022]
Abstract
Postoperative ileus (POI) is an abnormal pattern of gastrointestinal motility characterized by nausea, vomiting, abdominal distension and/or delayed passage of flatus or stool, which may occur following surgery. Postoperative ileus slows recovery, increases the risk of developing postoperative complications and confers a significant financial load on healthcare institutions. The aim of the present review is to provide a succinct overview of the clinical features and pathophysiological mechanisms of POI, with final comment on selected directions for future research.Terminology used when describing POI is inconsistent, with little differentiation made between the obligatory period of gut dysfunction seen after surgery ('normal POI') and the more clinically and pathologically significant entity of a 'prolonged POI'. Both normal and prolonged POI represent a fundamentally similar pathophysiological phenomenon. The aetiology of POI is postulated to be multifactorial, with principal mediators being inflammatory cell activation, autonomic dysfunction (both primarily and as part of the surgical stress response), agonism at gut opioid receptors, modulation of gastrointestinal hormone activity and electrolyte derangements. A final common pathway for these effectors is impaired contractility and motility and gut wall oedema. There are many potential directions for future research. In particular, there remains scope to accurately characterize the gastrointestinal dysfunction that underscores an ileus, development of an accurate risk stratification tool will facilitate early implementation of preventive measures and clinical appraisal of novel therapeutic strategies that target individual pathways in the pathogenesis of ileus warrant further investigation.
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Affiliation(s)
- Ryash Vather
- Department of Surgery, University of Auckland, Auckland, New Zealand
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70
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Srinivasa S, Taylor MH, Singh PP, Lemanu DP, MacCormick AD, Hill AG. Goal-directed fluid therapy in major elective rectal surgery. Int J Surg 2014; 12:1467-72. [DOI: 10.1016/j.ijsu.2014.11.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/04/2014] [Accepted: 11/08/2014] [Indexed: 01/05/2023]
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71
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Alfonsi P, Slim K, Chauvin M, Mariani P, Faucheron JL, Fletcher D. [Guidelines for enhanced recovery after elective colorectal surgery]. ACTA ACUST UNITED AC 2014; 33:370-84. [PMID: 24854967 DOI: 10.1016/j.annfar.2014.03.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Early recovery after surgery provides patients with all means to counteract or minimize the deleterious effects of surgery. This concept is suitable for a surgical procedure (e.g., colorectal surgery) and comes in the form of a clinical pathway that covers three periods (pre-, intra- and postoperative). The purpose of this Expert panel guideline is firstly to assess the impact of each parameter usually included in the rehabilitation programs on 6 foreseeable consequences of colorectal surgery: surgical stress, postoperative ileus, water and energy imbalance, postoperative immobility, sleep alterations and postoperative complications; secondly, to validate the usefulness of each as criteria of efficiency criteria for success of rehabilitation programs. Two main criteria were selected to evaluate the impact of each parameter: the length of stay and frequency of postoperative complications. Lack of information in the literature forced experts to assess some parameters with criteria (duration of postoperative ileus or quality of analgesia) that mainly surrogate a positive impact for the implementation of an early recovery program. After literature analysis, 19 parameters were identified as potentially interfering with at least one of the foreseeable consequences of colorectal surgery. GRADE® methodology was applied to determine a level of evidence and strength of recommendation. After synthesis of the work of experts using GRADE® method on 19 parameters, 35 recommendations were produced by the organizing committee. The recommendations were submitted and amended by a group of reviewers. After three rounds of Delphi quotes, strong agreement was obtained for 28 recommendations (80%) and weak agreement for seven recommendations. A consensus was reached among anesthesiologists and surgeons on a number of approaches that are likely not sufficiently applied for rehabilitation programs in colorectal surgery such as: preoperative intake of carbohydrates; intraoperative hemodynamic optimization; oral feeding resume before ha24; gum chewing after surgery; patient out of bed and walking at D1. The panel also clarified the value and place of such approaches such as: patient information; preoperative immunonutrition; laparoscopic surgery; antibiotic prophylaxis; prevention of hypothermia; systematic prevention of nausea and vomiting; morphine-sparing analgesic techniques; indications and techniques for bladder catheterization. The panel also confirmed the futility of approaches such as: bowel preparation for colon surgery; maintain of the nasogastric tube; surgical drainage for colonic surgery.
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Affiliation(s)
- P Alfonsi
- Service anesthésie-réanimation, hôpital Cochin, groupe hospitalier Paris Centre, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
| | - K Slim
- Service de chirurgie digestive, CHU Estaing, 1, rue Lucie-Aubrac, 63100 Clermont-Ferrand, France
| | - M Chauvin
- Service anesthésie-réanimation, hôpital Ambroise-Paré, AP-HP, 9, avenue Charles-de-Gaulle, 92104 Boulogne-Billancourt, France
| | - P Mariani
- Département de chirurgie, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - J-L Faucheron
- Service de chirurgie digestive, hôpital Michallon, CHU, BP 217, 39043 Grenoble cedex, France
| | - D Fletcher
- Service d'anesthésie, hôpital Raymond-Poincaré, AP-HP, 104, boulevard Raymond-Poincaré, 92380 Garches, France
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72
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Vather R, O'Grady G, Bissett IP, Dinning PG. Postoperative ileus: mechanisms and future directions for research. Clin Exp Pharmacol Physiol 2014. [DOI: 10.1111/1440-1681.12220 10.1016/j.ijge.2013.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Ryash Vather
- Department of Surgery; University of Auckland; Auckland New Zealand
| | - Greg O'Grady
- Department of Surgery; University of Auckland; Auckland New Zealand
| | - Ian P Bissett
- Department of Surgery; University of Auckland; Auckland New Zealand
| | - Phil G Dinning
- Departments of Gastroenterology and Surgery; Flinders Medical Centre; Flinders University; Adelaide SA Australia
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73
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Gritsenko K, Khelemsky Y, Kaye AD, Vadivelu N, Urman RD. Multimodal therapy in perioperative analgesia. Best Pract Res Clin Anaesthesiol 2014; 28:59-79. [PMID: 24815967 DOI: 10.1016/j.bpa.2014.03.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 02/26/2014] [Accepted: 03/04/2014] [Indexed: 12/22/2022]
Abstract
This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.
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Affiliation(s)
- Karina Gritsenko
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York, NY, USA; Department of Family and Social Medicine, Montefiore Medical Center, Bronx, New York, NY, USA; Acute Pain, Regional, Chronic Pain, Montefiore Medical Center, Bronx, New York, NY, USA; Albert Einstein College of Medicine, Yeshiva University, Montefiore Medical Center, Bronx, New York, NY, USA.
| | - Yury Khelemsky
- Anesthesiology, Icahn School of Medicine of Mount Sinai, New York, NY, USA; Pain Medicine Fellowship Program, Icahn School of Medicine of Mount Sinai, New York, NY, USA
| | - Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA; Interventional Pain Services, LSU School of Medicine, New Orleans, LA, USA; Department of Pharmacology, LSU School of Medicine, New Orleans, LA, USA; Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA, USA; Department of Pharmacology, Tulane School of Medicine, New Orleans, LA, USA
| | - Nalini Vadivelu
- Anesthesiology Department, Yale University School of Medicine, New Haven, CT, USA
| | - Richard D Urman
- Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Brigham and Women's Hospital, USA
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74
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Singh PP, Lemanu DP, Taylor MHG, Hill AG. Association between preoperative glucocorticoids and long-term survival and cancer recurrence after colectomy: follow-up analysis of a previous randomized controlled trial. Br J Anaesth 2014; 113 Suppl 1:i68-73. [PMID: 24583820 DOI: 10.1093/bja/aet577] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The effect of anaesthetic drugs on long-term oncological outcomes after cancer surgery is an area of current interest. Dexamethasone is widely used in anaesthetic practice; however, its effect on long-term survival and cancer outcomes is not known. This study presents the results of a 5-yr follow-up of patients receiving dexamethasone before elective colectomy as part of a previous randomized clinical trial. METHODS Sixty patients who underwent elective open colonic resection for any indication between June 2006 and March 2008 were randomized to receive either 8 mg i.v. dexamethasone or placebo before surgery. A 5-yr follow-up analysis was conducted to evaluate overall survival, disease-free survival and recurrence specifically for patients undergoing resection for Stage I-III colon cancer. Kaplan-Meier analysis was performed and log-rank test was used to evaluate difference in survival between groups. RESULTS Forty-three of the 60 subjects had Stage I-III colon cancer and were included in the follow-up analysis. Twenty received preoperative dexamethasone and 23 received placebo. There were no significant differences between groups in baseline or disease characteristics. No differences were found between groups for overall or disease-free survival. In the dexamethasone group, there was a significantly higher rate of distant recurrence (6 compared with 1, P=0.04). CONCLUSIONS Preoperative dexamethasone was associated with a higher rate of distant recurrence in patients undergoing colectomy for colon cancer. Given the small sample size, this finding should be interpreted with caution, but warrants further investigation in a prospective study.
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Affiliation(s)
- P P Singh
- Faculty of Medical and Health Sciences, Department of Surgery, South Auckland Clinical School, University of Auckland, Auckland, New Zealand
| | - D P Lemanu
- Faculty of Medical and Health Sciences, Department of Surgery, South Auckland Clinical School, University of Auckland, Auckland, New Zealand
| | - M H G Taylor
- Department of Anaesthesia, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - A G Hill
- Faculty of Medical and Health Sciences, Department of Surgery, South Auckland Clinical School, University of Auckland, Auckland, New Zealand
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Richardson AJ, Laurence JM, Lam VWT. Use of pre-operative steroids in liver resection: a systematic review and meta-analysis. HPB (Oxford) 2014; 16:12-9. [PMID: 23461716 PMCID: PMC3892310 DOI: 10.1111/hpb.12066] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 12/05/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND By attenuating the systemic inflammatory response to major surgery, the pre-operative administration of steroids may reduce the incidence of complications. METHODS A systematic review was conducted to identify randomized controlled trials (RCT) comparing pre-operative steroid administration with placebo during a liver resection. Meta-analyses were performed. RESULTS Five RCTs were identified including a total of 379 patients. Pre-operative steroids were associated with statistically significant reductions in the levels of serum bilirubin and interleukin 6 (IL-6) on post-operative day one. There was a trend towards a lower incidence of post-operative complications and prothrombin time (PT), but this did not reach statistical significance. CONCLUSION Pre-operative steroids may be associated with a clinically significant benefit in liver resection.
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Affiliation(s)
- Arthur J Richardson
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia; Discipline of Surgery, University of Sydney, Sydney, NSW, Australia
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Anesthesia, surgery, illness and Alzheimer's disease. Prog Neuropsychopharmacol Biol Psychiatry 2013; 47:162-6. [PMID: 22729032 PMCID: PMC3509241 DOI: 10.1016/j.pnpbp.2012.06.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 06/12/2012] [Accepted: 06/17/2012] [Indexed: 11/24/2022]
Abstract
Patients and their families have, for many decades, detected subtle changes in cognition subsequent to surgery, and only recently has this been subjected to scientific scrutiny. Through a combination of retrospective human studies, small prospective biomarker studies, and experiments in animals, it is now clear that durable consequences of both anesthesia and surgery occur, and that these intersect with the normal processes of aging, and the abnormal processes of chronic neurodegeneration. It is highly likely that inflammatory cascades are at the heart of this intersection, and if confirmed, this suggests a therapeutic strategy to mitigate enhanced neuropathology in vulnerable surgical patients.
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77
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Lunn TH, Kehlet H. Perioperative glucocorticoids in hip and knee surgery - benefit vs. harm? A review of randomized clinical trials. Acta Anaesthesiol Scand 2013; 57:823-34. [PMID: 23581549 DOI: 10.1111/aas.12115] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2013] [Indexed: 12/17/2022]
Abstract
Glucocorticoids are frequently used to prevent post-operative nausea and vomiting (PONV), and may be part of multimodal analgesic regimes. The objective of this review was to evaluate the overall benefit vs. harm of perioperative glucocorticoids in patients undergoing hip or knee surgery. A wide search was performed in PubMed, Embase, and Cochrane Central to identify relevant randomized clinical trials. A systematic approach was used, starting from the PRISMA recommendations. The Cochrane Collaboration's tool was used for risk of bias assessment. Studies were divided into three groups: systemic glucocorticoid administration analogous to > 10 mg or ≤ 10 mg dexamethasone, and local glucocorticoid administration. Seventeen studies with data from 1081 patients were included in the final qualitative synthesis. Benefit (of any kind) with glucocorticoid vs. placebo was reported in 15 studies. PONV was reduced with systemic glucocorticoid. Pain was reduced with high-dose systemic and local glucocorticoid, but not with low-dose systemic glucocorticoid. Systemic inflammatory markers were reduced with low-dose and high-dose systemic glucocorticoid, and with local glucocorticoid. Functional recovery was improved with local glucocorticoid. All studies were small-sized and none sufficiently powered to meaningfully evaluate uncommon adverse events. Most of the local administration studies had poor scientific quality (high risk of bias). Due to clinical heterogeneity and poor scientific quality, no meta-analysis was performed. In conclusion, in addition to PONV reduction with low-dose systemic glucocorticoid, this review supports high-dose systemic glucocorticoid to ameliorate post-operative pain after hip and knee surgery. However, large-scale safety and dose-finding studies are warranted before final recommendations.
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Affiliation(s)
- T H Lunn
- Department of Anaesthesiology, Hvidovre University Hospital, Copenhagen, Denmark.
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78
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Joshi GP, Bonnet F, Kehlet H. Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis 2013; 15:146-55. [PMID: 23350836 DOI: 10.1111/j.1463-1318.2012.03062.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The aim of this systematic review was to evaluate the available literature on the management of pain after laparoscopic colorectal surgery. METHOD Randomized studies, published in English between January 1995 and July 2011, assessing analgesic and anaesthetic interventions in adults undergoing laparoscopic colorectal surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. The efficacy and adverse effects of the analgesic techniques was assessed. The recommendations were based on procedure-specific evidence from a systematic review and supplementary transferable evidence from other relevant procedures. RESULTS Of the 170 randomized studies identified, 12 studies were included. Overall, all approaches including ketorolac, methylprednisolone, intraperitoneal instillation of ropivacaine, intravenous lidocaine infusion, intrathecal morphine and epidural analgesia improved pain relief, reduced opioid requirements and improved bowel function. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis. The L'Abbé plots of the data from the epidural analgesia studies included in this review indicate that the pain scores in the nonepidural groups, although higher than those in the epidural groups, were within an acceptable level (i.e. < 4/10). CONCLUSION Infiltration of surgical incisions with local anaesthetic at the end of surgery, systemic steroids, conventional nonsteroidal anti-inflammatory drugs or cyclooxygenase-2-selective inhibitors in combination with paracetamol with opioid used as rescue are recommended. Intravenous lidocaine infusion is recommended, but not as the first line of therapy. However, neuraxial blocks (i.e. epidural analgesia and spinal morphine) are not necessary based on high risk:benefit ratio.
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Affiliation(s)
- G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, Texas 75390-9068, USA.
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79
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Orci LA, Toso C, Mentha G, Morel P, Majno PE. Systematic review and meta-analysis of the effect of perioperative steroids on ischaemia-reperfusion injury and surgical stress response in patients undergoing liver resection. Br J Surg 2013; 100:600-9. [PMID: 23339056 DOI: 10.1002/bjs.9035] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2012] [Indexed: 12/31/2022]
Abstract
BACKGROUND Several therapeutic strategies, such as ischaemic preconditioning, intermittent or selective pedicle clamping and pharmacological interventions, have been explored to reduce morbidity caused by hepatic ischaemia-reperfusion injury and the surgical stress response. The role of steroids in this setting remains controversial. METHODS A comprehensive literature search in MEDLINE, Embase and the Cochrane Register of Clinical Trials (CENTRAL) was conducted (1966 onwards), identifying studies comparing perioperative administration of intravenous steroids with standard care or placebo, in the setting of liver surgery. Randomized Controlled trials (RCTs) and non-RCTs were included. Critical appraisal and meta-analysis were carried out according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement. RESULTS Six articles were included; five were RCTs. Pooling the results revealed that patients receiving intravenous glucocorticoids were 24 per cent less likely to suffer postoperative morbidity compared with controls (risk ratio 0.76, 95 per cent confidence interval 0.57 to 0.99; P = 0.047). The treated group experienced a significantly greater rise in early postoperative interleukin (IL) 10 levels compared with controls. In addition, steroids significantly reduced postoperative blood levels of bilirubin, and of inflammatory markers such as IL-6 and C-reactive protein. There was no evidence supporting a risk difference in infectious complications and wound healing between study groups. CONCLUSION Perioperative steroids have a favourable impact on postoperative outcomes after liver resection.
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Affiliation(s)
- L A Orci
- Hepatopancreaticobiliary Centre, Division of Visceral Surgery and Transplantation, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva 4, Switzerland.
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80
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Fawcett WJ, Mythen MG, Scott MJP. Enhanced recovery: more than just reducing length of stay? Br J Anaesth 2013; 109:671-4. [PMID: 23065999 DOI: 10.1093/bja/aes358] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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81
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Lunn T, Andersen L, Kristensen B, Husted H, Gaarn-Larsen L, Bandholm T, Ladelund S, Kehlet H. Effect of high-dose preoperative methylprednisolone on recovery after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial. Br J Anaesth 2013; 110:66-73. [DOI: 10.1093/bja/aes345] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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82
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Abstract
Enhanced recovery after surgery (ERAS) programs have been shown to minimise morbidity in other types of surgery, but comparatively less data exist investigating ERAS in bariatric surgery. This article reviews the existing literature to identify interventions which may be included in an ERAS program for bariatric surgery. A narrative literature review was conducted. Search terms included 'bariatric surgery', 'weight loss surgery', 'gastric bypass', 'ERAS', 'enhanced recovery', 'enhanced recovery after surgery', 'fast-track surgery', 'perioperative care', 'postoperative care', 'intraoperative care' and 'preoperative care'. Interventions recovered by the database search, as well as interventions garnered from clinical experience in ERAS, were used as individual search terms. A large volume of evidence exists detailing the role of multiple interventions in perioperative care. However, efficacy and safety for a proportion of these interventions for ERAS in bariatric surgery remain unclear. This review concludes that there is potential to implement ERAS programs in bariatric surgery.
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Srinivasa S, Singh SP, Kahokehr AA, Taylor MHG, Hill AG. Perioperative fluid therapy in elective colectomy in an enhanced recovery programme. ANZ J Surg 2012; 82:535-40. [DOI: 10.1111/j.1445-2197.2012.06122.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- H Kehlet
- Section for Surgical Pathophysiology 4074, Rigshospitalet Copenhagen University, Blegdamsvej 9, 2100 Copenhagen, Denmark.
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85
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Scientific Surgery. Br J Surg 2012. [DOI: 10.1002/bjs.8678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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86
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Lemanu D, Srinivasa S, Singh P, Kahokehr A, Zargar-Shoshtari K, Hill AG. Propensity score analysis evaluating preoperative glucocorticoid administration in elective colectomy. Int J Surg 2012; 10:607-10. [DOI: 10.1016/j.ijsu.2012.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 09/24/2012] [Accepted: 10/13/2012] [Indexed: 12/11/2022]
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87
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