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Miholjcic TBS, Baud O, Iranmanesh P, Wildhaber BE. Risk Factors for Dehiscence of Operative Incisions in Newborns after Laparotomy. Eur J Pediatr Surg 2024; 34:351-362. [PMID: 37816380 PMCID: PMC11226331 DOI: 10.1055/s-0043-1771223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/26/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Surgical wound dehiscence (SWD) in neonates is a life-threatening complication. The aim was to define risk factors of postoperative incision dehiscence in this population. METHODS Data of 144 patients from 2010 to 2020 were analyzed retrospectively. All full-term newborns or preterm newborns up to 42 weeks of amenorrhea (adjusted) who had a laparotomy within 30 days were included. Descriptive patient information and perioperative data were collected. SWD was defined as any separation of cutaneous edges of postoperative wounds. RESULTS Overall, SWD occurred in 16/144 (11%) patients, with a significantly increased incidence in preterm newborns (13/59, 22%) compared with full-term newborns (3/85, 4%; p < 0.001). SWD was significantly associated with exposure to postnatal steroids (60% vs. 4%, p < 0.001) and nonsteroidal anti-inflammatory drugs (25% vs. 4%, p < 0.01), invasive ventilation duration before surgery (median at 10 vs. 0 days, p < 0.001), preoperative low hemoglobin concentration (115 vs. 147 g/L, p < 0.001) and platelet counts (127 vs. 295 G/L, p < 0.001), nonabsorbable suture material (43% vs. 8%, p < 0.001), the presence of ostomies (69% vs. 18%, p < 0.001), positive bacteriological wound cultures (50% vs. 6%, p < 0.001), and relaparotomy (25% vs. 3%, p < 0.01). Thirteen of 16 patients with SWD presented necrotizing enterocolitis/intestinal perforations (81%, p < 0.001). CONCLUSION This study identified prematurity and a number of other factors linked to the child's general condition as risk factors for SWD. Some of these can help physicians recognize and respond to at-risk patients and provide better counseling for parents.
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Affiliation(s)
- Tina B. S. Miholjcic
- Division of Child and Adolescent Surgery, Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Olivier Baud
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Neonatal and Pediatric Intensive Care, Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Pouya Iranmanesh
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Barbara E. Wildhaber
- Division of Child and Adolescent Surgery, Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Lin VA, Hasselager RP, Fransgaard T, Gögenur I. Risk Factors for Persistent Postoperative Opioid Use After Surgery for IBD: An Observational Cohort Study. Dis Colon Rectum 2024; 67:951-959. [PMID: 38869466 DOI: 10.1097/dcr.0000000000003258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
BACKGROUND Patients with IBD are at increased risk of persistent opioid use, wherein surgery plays an important role. OBJECTIVE Identify risk factors for persistent postoperative opioid use in patients with IBD undergoing GI surgery and describe in-hospital postoperative opioid treatment. DESIGN This was a retrospective observational cohort study. ORs for persistent postoperative opioid use were calculated using preoperative and in-hospital characteristics, and in-hospital opioid use was described using oral morphine equivalents. SETTING This study was conducted at a university hospital with a dedicated IBD surgery unit. PATIENTS Patients who underwent surgery for IBD from 2017 to 2022 were included. MAIN OUTCOME MEASURES Our main outcome measure was persistent postoperative opioid use (1 or more opioid prescriptions filled 3-9 months postoperatively). RESULTS We included 384 patients, of whom 36 (9.4%) had persistent postoperative opioid use, but only 11 (2.9%) of these patients were opioid naive preoperatively. We identified World Health Organization performance status >1 (OR 8.21; 95% CI, 1.19-48.68), preoperative daily opioid use (OR 12.84; 95% CI, 4.78-35.36), psychiatric comorbidity (OR 3.89; 95% CI, 1.29-11.43) and in-hospital mean daily opioid use (per 10 oral morphine equivalent increase; OR 1.22; 95% CI, 1.12-1.34) as risk factors for persistent postoperative opioid use using multivariable regression analysis. LIMITATIONS Our observational study design and limited sample size because of it being a single-center study resulted in wide CIs. CONCLUSIONS We identified risk factors for persistent postoperative opioid use in patients undergoing surgery for IBD. Results indicate a need for optimization of pain treatment in patients with IBD both before and after surgery. These patients might benefit from additional opioid-sparing measures. See Video Abstract. FACTORES DE RIESGO EN LA ADMINISTRACION DURADERA DE OPIOIDES EN EL POSTOPERATORIO EN CASOS DE CIRUGA POR ENFERMEDAD INFLAMATORIA INTESTINAL ESTUDIO OBSERVACIONAL DE COHORTES ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de recibir opioides de manera duradera, casos donde la cirugía juega un papel importante.OBJETIVO:Identificar los factores de riesgo en la administración duradera de opioides en el post-operatorio de cirugía gastrointestinal en casos de EII y describir el tratamiento intra-hospitalario con los mismos.DISEÑO:Estudio observacional retrospectivo de cohortes. La relación de probabilidades (odds ratio - OR) en la adminstracion duradera de opioides post-operatorios fué calculada utilizando las características pré-operatorias y hospitalarias, donde la administración de opioides intra-hospitalarios fué descrita con la utilización de equivalentes de morfina oral.AMBIENTE:Estudio realizado en un hospital universitario con una unidad de cirugía dedicada a la EII.PACIENTES:Se incluyeron todos los pacientes sometidos a cirugía por EII entre 2017 y 2022.PRINCIPALES MEDIDAS DE RESULTADO:Nuestra principal medida de resultado fué la administración post-operatoria duradera de opioides (≥1 receta completa de opioides entre 3 y 9 meses después de la operación).RESULTADOS:Incluimos 384 pacientes, de los cuales 36 (9,4%) recibieron opioides de manera duradera en el post-operatorio, de los cuales solamente 11 pacientes (2,9%) no habían recibido opioides antes de la operación. Identificamos el estado funcional de la OMS > 1 (OR 8,21, IC 95% 1,19-48,68), el uso diario de opioides pré-operatorios (OR 12,84, IC 95% 4,78-35,36), los casos de comorbilidad psiquiátrica (OR 3,89, IC 95% 1,29-11,43) y el uso medio diario de opioides en el hospital (por cada aumento de 10 equivalentes de morfina oral) (OR 1,22, IC del 95%: 1,12-1,34 como factores de riesgo para la administración de opioides de manera duradera en el post-operatorio mediante el análisis de regresión multivariable.LIMITACIONES:Nuestro diseño de estudio observacional y el tamaño de la muestra limitada debido a que fue un estudio en un solo centro, dando como resultado intervalos de confianza muy amplios.CONCLUSIONES:Se identificaron los factores de riesgo en la administración duradera de opioides en el post-operatorio de cirugía gastrointestinal en casos de EII. Los resultados demuestran la necesidad de optimizar el tratamiento del dolor en pacientes con EII, tanto antes como después de la cirugía. Estos pacientes podrían beneficiarse de medidas adicionales de ahorro de opioides. (Traducción-Dr. Xavier Delgadillo).
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Affiliation(s)
- Viviane A Lin
- Department of Surgery, Center for Surgical Science, Zealand University Hospital Køge, Køge, Denmark
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Zhuang ZM, Wang Y, Feng ZX, Lin XY, Wang ZC, Zhong XC, Guo K, Zhong YF, Fang QQ, Wu XJ, Chen J, Tan WQ. Targeting Diverse Wounds and Scars: Recent Innovative Bio-design of Microneedle Patch for Comprehensive Management. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024; 20:e2306565. [PMID: 38037685 DOI: 10.1002/smll.202306565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/16/2023] [Indexed: 12/02/2023]
Abstract
Wounds and the subsequent formation of scars constitute a unified and complex phased process. Effective treatment is crucial; however, the diverse therapeutic approaches for different wounds and scars, as well as varying treatment needs at different stages, present significant challenges in selecting appropriate interventions. Microneedle patch (MNP), as a novel minimally invasive transdermal drug delivery system, has the potential for integrated and programmed treatment of various diseases and has shown promising applications in different types of wounds and scars. In this comprehensive review, the latest applications and biotechnological innovations of MNPs in these fields are thoroughly explored, summarizing their powerful abilities to accelerate healing, inhibit scar formation, and manage related symptoms. Moreover, potential applications in various scenarios are discussed. Additionally, the side effects, manufacturing processes, and material selection to explore the clinical translational potential are investigated. This groundwork can provide a theoretical basis and serve as a catalyst for future innovations in the pursuit of favorable therapeutic options for skin tissue regeneration.
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Affiliation(s)
- Ze-Ming Zhuang
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, P. R. China
| | - Yong Wang
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, P. R. China
| | - Zi-Xuan Feng
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, P. R. China
| | - Xiao-Ying Lin
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, P. R. China
| | - Zheng-Cai Wang
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, P. R. China
| | - Xin-Cao Zhong
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, P. R. China
| | - Kai Guo
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, P. R. China
| | - Yu-Fan Zhong
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, P. R. China
| | - Qing-Qing Fang
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, P. R. China
| | - Xiao-Jin Wu
- Department of Ultrasound in Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, P. R. China
| | - Jian Chen
- Department of Ultrasound in Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, P. R. China
| | - Wei-Qiang Tan
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, 310016, P. R. China
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Non-Surgical Interventions for the Prevention of Clinically Relevant Postoperative Pancreatic Fistula-A Narrative Review. Cancers (Basel) 2023; 15:5865. [PMID: 38136409 PMCID: PMC10741911 DOI: 10.3390/cancers15245865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is the leading cause of morbidity and mortality after pancreatic surgery. Post-pancreatectomy acute pancreatitis (PPAP) has been increasingly understood as a precursor and exacerbator of CR-POPF. No longer believed to be the consequence of surgical technique, the solution to preventing CR-POPF may lie instead in non-surgical, mainly pharmacological interventions. Five databases were searched, identifying eight pharmacological preventative strategies, including neoadjuvant therapy, somatostatin and its analogues, antibiotics, analgesia, corticosteroids, protease inhibitors, miscellaneous interventions with few reports, and combination strategies. Two further non-surgical interventions studied were nutrition and fluids. New potential interventions were also identified from related surgical and experimental contexts. Given the varied efficacy reported for these interventions, numerous opportunities for clarifying this heterogeneity remain. By reducing CR-POPF, patients may avoid morbid sequelae, experience shorter hospital stays, and ensure timely delivery of adjuvant therapy, overall aiding survival where prognosis, particularly in pancreatic cancer patients, is poor.
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Affiliation(s)
- Nadya Rykina-Tameeva
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
| | - Jaswinder S. Samra
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Sumit Sahni
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Anubhav Mittal
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
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Ju JW, Lee HJ, Kim MJ, Ryoo SB, Kim WH, Jeong SY, Park KJ, Park JW. Postoperative NSAIDs use and the risk of anastomotic leakage after restorative resection for colorectal cancer. Asian J Surg 2023; 46:4749-4754. [PMID: 37105812 DOI: 10.1016/j.asjsur.2023.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/06/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Although non-steroidal anti-inflammatory drugs (NSAIDs) are useful options for multimodal opioid-sparing analgesia, their effect on anastomotic leakage (AL) after colorectal surgery remains unclear. We aimed to investigate the association between early postoperative NSAID use and AL occurrence in patients who underwent colorectal cancer surgery at a high-volume tertiary care center. METHODS This retrospective observational study included all adult patients who underwent elective colorectal cancer resection surgery during 2011-2021 at a tertiary teaching hospital. Based on NSAID use within five postoperative days, patients were classified into either NSAID or no NSAID groups. We performed multivariable logistic regression analysis for the primary outcome, AL, within the first 30 postoperative days, before and after propensity score analysis using stabilized inverse probability of treatment weighting (sIPTW). RESULTS Among the 7928 patients analyzed, 0.6% experienced AL after surgery. The occurrence rates of AL were 1.7% (12/714) and 0.5% (37/7214) in the NSAID and no NSAID groups, respectively. Multivariable logistic regression analysis revealed that early postoperative NSAID use was significantly associated with AL [odds ratio (OR), 3.41; 95% confidence interval (CI), 1.76-6.60; P < 0.001]. Significance was maintained after sIPTW (OR, 3.65; 95% CI, 1.86-6.72; P < 0.001). CONCLUSION Early postoperative NSAID use was significantly associated with AL in patients undergoing colorectal cancer surgery at a high-volume tertiary care center. Further prospective studies are required to investigate NSAIDs' clinically meaningful unfavorable effects following colorectal cancer surgery.
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Affiliation(s)
- Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Min Jung Kim
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung-Bum Ryoo
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung-Yong Jeong
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyu Joo Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji Won Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea.
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Aiolfi A, Bonitta G, Campanelli G, Bona D. Impact of postoperative NSAIDs administration on anastomotic leak after esophago-gastric surgery: systematic review and meta-analysis. Updates Surg 2023:10.1007/s13304-023-01515-6. [PMID: 37186272 DOI: 10.1007/s13304-023-01515-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
Anastomotic leak (AL) is a feared complication of esophago-gastric surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat postoperative pain. Previous analyses conveyed heterogeneous data for colorectal surgery with a tendency toward high risk for AL after NSAIDs administration. In the setting of upper gastrointestinal (GI) surgery data are even more puzzled. The purpose of the present study was to assess whether an association exists between postoperative NSAIDs administration and AL after esophago-gastric surgery. PubMed, MEDLINE, Scopus, and Web of Science were searched up to November 2022. The included studies evaluated outcomes for NSAIDs vs. no NSAIDs administration after esophago-gastric surgery. The primary outcome was anastomotic leak (AL). Risk ratio (RR) and 95% confidence intervals (95% CI) were used to assess pooled effect size and relative inference. Six studies (43,784 patients) were included. The patient age ranged from 31 to 84 years, 82.4% were males and preoperative BMI ranged from 15 to 31 kg/m2. Esophagectomy was performed in 95% of patients. NSAIDs were administered in 18,075 (41.3%) patients. The cumulative incidence of AL was similar for NSAIDs vs. no NSAIDs (13.6% vs. 13.4%). The risk for postoperative AL was similar for NSAIDs vs. no NSAIDs administration (RR 1.49; 95% CI 0.81-2.75; p = 0.19). The cumulative incidence of postoperative gastrointestinal bleeding (0.36% vs. 0.39%), acute kidney injury (0.62% vs. 0.71%), and in-hospital mortality (2.39% vs. 2.66%) were comparable. NSAIDs administration for postoperative analgesia seems not associated with an increased risk for AL after esophago-gastric surgery.
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Affiliation(s)
- Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Via C. Belgioioso N.173, 20151, Milan, Italy.
| | - Gianluca Bonitta
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Via C. Belgioioso N.173, 20151, Milan, Italy
| | - Giampiero Campanelli
- Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Insubria, Varese, Italy
| | - Davide Bona
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Via C. Belgioioso N.173, 20151, Milan, Italy
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Impact of postoperative NSAIDs (IV-PCA) use on short-term outcomes after laparoscopic gastrectomy for the patients of gastric cancer. Surg Endosc 2023; 37:1123-1131. [PMID: 36131159 DOI: 10.1007/s00464-022-09600-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Further data are necessary to evaluate the risk of complications associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) postoperatively. This study aimed to determine the correlation between the use of NSAIDs in intravenous patient-controlled analgesia (IV-PCA) and postoperative complications after laparoscopic gastrectomy in patients with gastric cancer. METHODS This retrospective, single-center study was conducted. The study population comprised 2150 patients who underwent laparoscopic gastrectomy for gastric cancer treatment. They were divided into two groups: non-NSAIDs (n = 1215) and NSAIDs (n = 935) according to their use of the drugs. Clinicopathologic characteristics, operative details, postoperative complications within 30 days, risk factors for complications, and survival were analyzed. RESULTS Of the 2150 patients, 935 (43.49%) used NSAIDs. The overall complication rate showed no significant difference between the NSAIDs and non-NSAIDs groups (22.7% vs. 20.7%, p = 0.280), while the rates of anastomotic leakage and duodenal leakage were higher in the NSAID group (2.4% vs. 0.7%, p = 0.002 and 1.8% vs. 0.6%, p = 0.007, respectively). The rates of intra-abdominal bleeding and intra-abdominal abscess were significantly higher in the NSAID group (2.1% vs. 0.7%, p = 0.005 and 1.5% vs. 0.4%, p = 0.008, respectively). However, postoperative ileus occurred more frequently in the non-NSAID group (3.0% vs. 1.4%, p = 0.015). On multivariate analysis, NSAID use was an independent risk factor for early postoperative complications (1.303 [1.042-1.629], p = 0.020). Meanwhile, the NSAID group showed no differences in overall survival at each pathological stage. CONCLUSION Postoperative NSAID use by IV-PCA is associated with anastomotic leakage, duodenal stump leakage, intra-abdominal bleeding, and intra-abdominal abscess in patients who underwent laparoscopic gastrectomy for gastric cancer. Caution is advised when NSAIDs are used peri-operatively.
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Hirano Y, Konishi T, Kaneko H, Itoh H, Matsuda S, Kawakubo H, Uda K, Matsui H, Fushimi K, Daiko H, Itano O, Yasunaga H, Kitagawa Y. Early postoperative non-steroidal anti-inflammatory drugs and anastomotic leakage after oesophagectomy. Br J Surg 2023; 110:260-266. [PMID: 36433812 DOI: 10.1093/bjs/znac399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/10/2022] [Accepted: 10/31/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Previous studies have suggested that postoperative non-steroidal anti-inflammatory drug (NSAID) use may increase the risk of anastomotic leakage after colorectal surgery. However, the association between NSAIDs and anastomotic leakage after oesophagectomy is unclear. The aim of this retrospective study was to assess the effect of early postoperative NSAID use on anastomotic leakage after oesophagectomy. METHODS The Data of patients who underwent oesophagectomy for cancer between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the association between NSAID use in the early postoperative period (defined as the day of and the day after surgery) and short-term outcomes, adjusting for potential confounders. The primary outcome was anastomotic leakage. The secondary outcomes were acute kidney injury, gastrointestinal bleeding, and mortality. RESULTS Among 39 418 eligible patients, early postoperative NSAIDs were used by 16 211 individuals (41 per cent). Anastomotic leakage occurred in 5729 patients (15 per cent). In stabilized IPTW analyses, NSAIDs were not associated with anastomotic leakage (odds ratio 1.04, 95 per cent c.i. 0.97 to 1.10). The proportions of acute kidney injury and gastrointestinal bleeding, as well as 30-day mortality and in-hospital mortality, did not differ according to NSAID use. Propensity score matching and instrumental variable analyses demonstrated similar results. CONCLUSION Early postoperative NSAID use was not associated with anastomotic leakage or other complications in patients who underwent oesophagectomy.
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Affiliation(s)
- Yuki Hirano
- Department of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Chiba, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hidehiro Kaneko
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Hidetaka Itoh
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazuaki Uda
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Osamu Itano
- Department of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Chiba, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Hyland SJ, Wetshtein AM, Grable SJ, Jackson MP. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare (Basel) 2022; 11:healthcare11010034. [PMID: 36611494 PMCID: PMC9818465 DOI: 10.3390/healthcare11010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
- Correspondence:
| | - Andrea M. Wetshtein
- Department of Pharmacy, Cleveland Clinic Fairview Hospital, Cleveland, OH 44111, USA
| | - Samantha J. Grable
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
| | - Michelle P. Jackson
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
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Hirano Y, Kaneko H, Konishi T, Itoh H, Matsuda S, Kawakubo H, Uda K, Matsui H, Fushimi K, Daiko H, Itano O, Yasunaga H, Kitagawa Y. Short-Term Outcomes of Epidural Analgesia in Minimally Invasive Esophagectomy for Esophageal Cancer: Nationwide Inpatient Data Study in Japan. Ann Surg Oncol 2022; 29:8225-8234. [PMID: 35960454 DOI: 10.1245/s10434-022-12346-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/12/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Studies have shown that epidural analgesia (EDA) is associated with a decreased risk of pneumonia and anastomotic leakage after esophagectomy, and several guidelines strongly recommend EDA use after esophagectomy. However, the benefit of EDA use in minimally invasive esophagectomy (MIE) remains unclear. OBJECTIVE The aim of this retrospective study was to compare the short-term outcomes between patients with and without EDA undergoing MIE for esophageal cancer. METHODS Data of patients who underwent oncologic MIE (April 2014-March 2019) were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the associations between EDA use and short-term outcomes, adjusting for potential confounders. RESULTS Among 12,688 eligible patients, EDA was used in 9954 (78.5%) patients. In-hospital mortality, respiratory complications, and anastomotic leakage occurred in 230 (1.8%), 2139 (16.9%), and 1557 (12.3%) patients, respectively. In stabilized IPTW, EDA use was significantly associated with decreased in-hospital mortality (odds ratio [OR] 0.46 [95% confidence interval 0.34-0.61]), respiratory complications (OR 0.74 [0.66-0.84]), and anastomotic leakage (OR 0.77 [0.67-0.88]). EDA use was also associated with decreased prolonged mechanical ventilation, unplanned intubation, nonsteroidal anti-inflammatory drug use, acetaminophen use, postoperative length of stay, and total hospitalization costs and increased vasopressor use. One-to-three propensity score matching and instrumental variable analyses demonstrated equivalent results. CONCLUSIONS EDA use in oncologic MIE was associated with low in-hospital mortality as well as decreased respiratory complications, and anastomotic leakage, suggesting the potential advantage of EDA use in MIE.
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Affiliation(s)
- Yuki Hirano
- Department of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan.
| | - Hidehiro Kaneko
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hidetaka Itoh
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazuaki Uda
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Osamu Itano
- Department of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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11
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Olsen AA, Svendsen LB, Achiam MP. Mesenteric traction syndrome – It is not just benign flushing. J Clin Anesth 2022; 80:110822. [DOI: 10.1016/j.jclinane.2022.110822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 01/23/2023]
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12
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Nie H, Hao Y, Feng X, Ma L, Ma Y, Zhang Z, Han X, Zhang JZ, Zhang P, Zhao Q, Dong H. Postoperative short-term use of the nonsteroidal anti-inflammatory drug flurbiprofen did not increase the anastomotic leakage rate in patients undergoing elective gastrointestinal surgery-a retrospective cohort study. Perioper Med (Lond) 2022; 11:38. [PMID: 35982476 PMCID: PMC9389786 DOI: 10.1186/s13741-022-00275-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background Flurbiprofen has been one of the most commonly used nonsteroidal anti-inflammatory drugs (NSAIDs) in China and other Asian countries for perioperative multimodal analgesia in recent years, yet its association with anastomotic leakage in gastrointestinal anastomoses is unknown. The current study was designed to investigate whether short-term administration of flurbiprofen would increase the risk of anastomotic leakage in patients undergoing gastrointestinal surgery for cancer resection. Methods A total of 3653 patients (2487 (66.1%) men) undergoing elective operation for gastrointestinal cancer between 18 July 2017 and 30 Oct 2020 were included. The median age was 61 years (interquartile range 53–67 years). The exposure was the short-term postoperative use of flurbiprofen (defined as flurbiprofen treatment within the first week after surgery). The primary outcome was the frequency of clinical anastomotic leakage. Results Of 3653 patients with available data who were included in the final analysis, 2282 received flurbiprofen administration, and 1371 did not. Anastomotic leakage was not significantly increased among the patients receiving flurbiprofen compared with those who did not (1.62% v 1.46%; P=0.70). In-hospital mortality was comparable between the two groups (0.04% v 0.07%; P=0.72). After adjusted analysis, male sex (OR 3.51, 95% CI 1.80–6.85), ASA score of 3–4 (OR 2.69, 95% CI 1.62–4.48), and intraoperative infusion (OR 2.24, 95% CI 1.19–4.21) were identified as risk factors for anastomotic leakage. Conclusions Postoperative short-term use of flurbiprofen did not increase the risk of anastomotic leakage in gastrointestinal anastomoses.
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Affiliation(s)
- Huang Nie
- Department of Anesthesiology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Yiming Hao
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Xiangying Feng
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Lina Ma
- Department of Anesthesiology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Yumei Ma
- Department of Anesthesiology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Zhen Zhang
- Department of Anesthesiology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Xi'an Han
- The Unimed Scientific, Inc., Wu Xi, China
| | | | - Ping Zhang
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Qingchuan Zhao
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China.
| | - Hailong Dong
- Department of Anesthesiology, Xijing Hospital, Air Force Medical University, Xi'an, China.
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13
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Comparison of the Analgesic Efficacy of Opioid-Sparing Multimodal Analgesia and Morphine-Based Patient-Controlled Analgesia in Minimally Invasive Surgery for Colorectal Cancer. World J Surg 2022; 46:1788-1795. [DOI: 10.1007/s00268-022-06473-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 10/18/2022]
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14
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Wu CY, Cheng KC, Chen YJ, Lu CC, Lin YM. Risk of NSAID-associated anastomosis leakage after colorectal surgery: a large-scale retrospective study using propensity score matching. Int J Colorectal Dis 2022; 37:1189-1197. [PMID: 35476135 DOI: 10.1007/s00384-022-04160-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE NSAIDs are commonly used as opioid-sparing analgesics in colorectal surgery. Many efforts are made to elucidate the risk of NSAID-associated anastomotic leakage after colorectal surgery. However, these results still remain controversial. In this study, we applied large-scale retrospective analysis using propensity score matching to fully clarify the association between risk of anastomotic leakage and use of NSAID after colorectal surgery. METHODS All colorectal cancer patients receiving operation during February 2008 to August 2018 in our multi-institution medical organization research database were enrolled. It is worthy to mention that only patients requiring re-operation within 21 days after colorectal surgery due to anastomotic leakage were counted as anastomosis leakage. Furthermore, a propensity score TriMatch analysis was performed to prevent from interference of confounding factors. RESULTS A total of 10,584 patients were included in this study and divided into three groups, no NSAIDs group, non-selective NSAIDs group, and selective COX-2 inhibitors group, respectively. Before tri-matching analysis, significant differences in anastomotic leakage rate were observed. After propensity score matching analysis, the ratio of anastomotic leakage requiring re-operation occurred in 2.0%, 3.6%, and 2.0% in no NSAIDs, non-selective NSAIDs, and selective COX-2 inhibitors group, respectively. No significant difference was observed in these three groups. CONCLUSION These results suggest that NSAIDs are not associated with incidence of anastomosis leakage following colorectal surgery. To our knowledge, it is the first study demonstrating that NSAIDs is not associated with incidence of anastomosis leakage following colorectal surgery using propensity score matching at a larger-scale retrospective study.
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Affiliation(s)
- Chien-Ying Wu
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Niaosong District, No.123, Dapi Road, 833, Kaohsiung, Taiwan
| | - Kung-Chuan Cheng
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Niaosong District, No.123, Dapi Road, 833, Kaohsiung, Taiwan
| | - Yun-Ju Chen
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan.,Department of Medical Research, E-Da Hospital, Kaohsiung, Taiwan
| | - Chien-Chang Lu
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Niaosong District, No.123, Dapi Road, 833, Kaohsiung, Taiwan
| | - Yueh-Ming Lin
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Niaosong District, No.123, Dapi Road, 833, Kaohsiung, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
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15
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McEvoy MD, Raymond BL, Krige A. Opioid-Sparing Perioperative Analgesia Within Enhanced Recovery Programs. Anesthesiol Clin 2022; 40:35-58. [PMID: 35236582 DOI: 10.1016/j.anclin.2021.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Opioid-based analgesia in the perioperative period can provide excellent pain control, but this approach exposes the patient to avoidable side effects and possible harm. Optimal analgesia, an approach that targets the fastest functional recovery with adequate pain control while minimizing side effects, can be achieved with opioid minimization. Many different options for nonopioid multimodal analgesia exist and have been shown to be efficacious, with certain modalities being more beneficial for specific surgeries. This review will present the evidence and practical tips for these management strategies.
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University School of Medicine, 1301 Medical Center Drive, TVC 4619, Nashville, TN 37221, USA; Perioperative Medicine Fellowship, Hi-RiSE Perioperative Optimization Clinic, Perioperative Consult Service, VUMC ERAS Executive Steering Committee, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN 37232, USA.
| | - Britany L Raymond
- Department of Anesthesiology, Vanderbilt University School of Medicine, 1301 Medical Center Drive, TVC 4619, Nashville, TN 37221, USA; Perioperative Medicine Fellowship, Hi-RiSE Perioperative Optimization Clinic, Perioperative Consult Service, VUMC ERAS Executive Steering Committee, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN 37232, USA
| | - Anton Krige
- Department of Anaesthesia and Critical Care, Royal Blackburn Teaching Hospital, Haslingden Road, Blackburn BB2 3HH, UK
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16
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Immune Modulatory Effects of Nonsteroidal Anti-inflammatory Drugs in the Perioperative Period and Their Consequence on Postoperative Outcome. Anesthesiology 2022; 136:843-860. [PMID: 35180291 DOI: 10.1097/aln.0000000000004141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nonsteroidal anti-inflammatory drugs are among the most commonly administered drugs in the perioperative period due to their prominent role in pain management. However, they potentially have perioperative consequences due to immune-modulating effects through the inhibition of prostanoid synthesis, thereby affecting the levels of various cytokines. These effects may have a direct impact on the postoperative outcome of patients since the immune system aims to restore homeostasis and plays an indispensable role in regeneration and repair. By affecting the immune response, consequences can be expected on various organ systems. This narrative review aims to highlight these potential immune system-related consequences, which include systemic inflammatory response syndrome, acute respiratory distress syndrome, immediate and persistent postoperative pain, effects on oncological and neurologic outcome, and wound, anastomotic, and bone healing.
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17
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Lee L, Fiore JF. NSAIDs and anastomotic leak: What's the evidence? SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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Kastora SL, Osborne LL, Jardine R, Kounidas G, Carter B, Myint PK. Non-steroidal anti-inflammatory agents and anastomotic leak rates across colorectal cancer operations and anastomotic sites: A systematic review and meta-analysis of anastomosis specific leak rate and confounding factors. Eur J Surg Oncol 2021; 47:2841-2848. [PMID: 34099356 DOI: 10.1016/j.ejso.2021.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Surgical intervention presents a fundamental therapeutic choice in the management of colorectal malignancies. Complications, the most serious one being anastomotic leak (AL), still have detrimental effects upon patients' morbidity and mortality. We aimed to assess whether NSAIDs, and their sub-categories, increase AL in colonic anastomoses and to identify whether this affects specific anastomotic sites. MATERIALS AND METHODS A systematic search of MEDLINE, Cochrane Library, ClinicalTrials.gov, Web of Science, Science Direct, Google Scholar was conducted between January 1, 1999 till the October 30, 2020. Cohort studies and randomized control trials examining AL events in NSAID-exposed, colorectal cancer patients were included. NSAIDs were grouped according to the 2019 NICE guidelines in non-specific (NS-NSAIDs) and specific COX-2 inhibitors. The primary outcome was AL events in NSAID-exposed patients undergoing operations with either ileocolic, colocolic or colorectal anastomoses. Secondary outcomes included NSAID category-specific AL events and demographic confounding factors increasing AL risk in this patient population. RESULTS Fifteen studies involving 25,395 patients were included in the systematic review and meta-analysis. Of all anastomoses, colocolic anastomoses were found to be statistically more prone to AL events in the NS-NSAID-exposed population [OR 3.24 (95% CI 0.98-10.72), p = 0.054]. Male gender was an independent confounder increasing AL rate regardless of NSAID exposure. CONCLUSION The association between NSAID exposure and AL in oncology patients remains undetermined. Whilst in present work, colocolic anastomoses appear to be more sensitive to AL events, the observed association may be anastomotic site and NSAID-category dependent.
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Affiliation(s)
- S L Kastora
- University of Aberdeen, School of Medicine, Medical Sciences and Nutrition, United Kingdom.
| | - L L Osborne
- University of Aberdeen, School of Medicine, Medical Sciences and Nutrition, United Kingdom
| | - R Jardine
- University of Aberdeen, School of Medicine, Medical Sciences and Nutrition, United Kingdom
| | - G Kounidas
- University of Aberdeen, School of Medicine, Medical Sciences and Nutrition, United Kingdom
| | - B Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College, London, United Kingdom
| | - P K Myint
- University of Aberdeen, School of Medicine, Medical Sciences and Nutrition, United Kingdom
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19
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Yoon S, Kim H, Cho HY, Lee HJ, Kim H, Lee HC, Jang JY. Effect of postoperative non-steroidal anti-inflammatory drugs on anastomotic leakage after pancreaticoduodenectomy. Korean J Anesthesiol 2021; 75:61-70. [PMID: 34024090 PMCID: PMC8831434 DOI: 10.4097/kja.21096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Although the association between an increase in anastomotic leakage (AL) and non-steroidal anti-inflammatory drugs (NSAIDs) has been reported in gastrointestinal surgeries, this issue has rarely been addressed for pancreaticoduodenectomy (PD). We aimed to investigate the association between postoperative NSAIDs administration and clinically relevant AL (CR-AL) following PD. Method We retrospectively evaluated 2,163 consecutive patients who underwent PD between 2007 and 2019. The patients were divided into two groups: patients who received and did not receive NSAIDs by postoperative day (POD) 5. We conducted a propensity score analysis using inverse probability of treatment weighting (IPTW) to adjust the baseline differences between both groups. We compared the occurrence of CR-AL and other postoperative outcomes before and after IPTW. Further, we used the multivariable binary logistic regression method for a sensitivity analysis for CR-AL. Results A total of 2,136 patients were included in the analysis. Of these, 222 (10.4%) received NSAIDs by POD 5. The overall occurrence rate of CR-AL was 14.9%. After IPTW, postoperative NSAIDs were significantly associated with CR-AL (odds ratio [OR] 1.24, 95% confidence interval [CI], 1.05-1.47; P=0.012), prolonged postoperative hospitalization (OR 1.31, 95% CI 1.14-1.50, P<0.001), and unplanned readmission within 30 days postoperatively (OR 1.48, 95% CI 1.15-1.91, P=0.002). However, this association was not consistent in the sensitivity analysis. Conclusion Postoperative NSAIDs use was significantly associated with an increase in CR-AL incidence following PD. However, sensitivity analysis failed to show its association, which precludes a firm conclusion of its detrimental effect.
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Affiliation(s)
- Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyerin Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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20
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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21
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The anabolic role of the Warburg, Cori-cycle and Crabtree effects in health and disease. Clin Nutr 2021; 40:2988-2998. [PMID: 33674148 DOI: 10.1016/j.clnu.2021.02.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Abstract
In evolution, genes survived that could code for metabolic pathways, promoting long term survival during famines or fasting when suffering from trauma, disease or during physiological growth. This requires utilization of substrates, already present in some form in the body. Carbohydrate stores are limited and to survive long, their utilization is restricted to survival pathways, by inhibiting glucose oxidation and glycogen synthesis. This leads to insulin resistance and spares muscle protein, because being the main supplier of carbon for new glucose production. In these survival pathways, part of the glucose is degraded in glycolysis in peripheral (muscle) tissues to pyruvate and lactate (Warburg effect), which are partly reutilized for glucose formation in liver and kidney, completing the Cori-cycle. Another part of the glucose taken up by muscle contributes, together with muscle derived amino acids, to the production of substrates consisting of a complete amino acid mix but extra non-essential amino acids like glutamine, alanine, glycine and proline. These support cell proliferation, matrix deposition and redox regulation in tissues, specifically active in host response and during growth. In these tissues, also glucose is taken up delivering glycolytic intermediates, that branch off and act as building blocks and produce reducing equivalents. Lactate is also produced and released in the circulation, adding to the lactate released by muscle in the Cori-cycle and completing secondary glucose cycles. Increased fluxes through these cycles lead to modest hyperglycemia and hyperlactatemia in states of healthy growth and disease and are often misinterpreted as induced by hypoxia.
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22
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Nascimbeni R, Amato A, Cirocchi R, Serventi A, Laghi A, Bellini M, Tellan G, Zago M, Scarpignato C, Binda GA. Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper. Tech Coloproctol 2020; 25:153-165. [PMID: 33155148 PMCID: PMC7884367 DOI: 10.1007/s10151-020-02346-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/08/2020] [Indexed: 12/21/2022]
Abstract
Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.
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Affiliation(s)
- R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25124, Brescia, Italy.
| | - A Amato
- Unit of Coloproctology, Department of Surgery, Borea Hospital, Sanremo, Italy
| | - R Cirocchi
- Department of Surgical and Medical Sciences, University of Perugia, Terni, Italy
| | - A Serventi
- Department of Surgery, Galliano Hospital, Acqui Terme, Italy
| | - A Laghi
- Department of Surgical-Medical Sciences and Translational Medicine, "Sapienza" University of Rome, Rome, Italy
| | - M Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - G Tellan
- Department of Internal, Anesthesiological and Cardiovascular Clinical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - M Zago
- Department of Robotic and Emergency Surgery, Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - C Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta
- Faculty of Medicine, Chinese University of Hong Kong, ShaTin, Hong Kong
| | - G A Binda
- General Surgery, Biomedical Institute, Genoa, Italy
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Reischl S, Wilhelm D, Friess H, Neumann PA. Innovative approaches for induction of gastrointestinal anastomotic healing: an update on experimental and clinical aspects. Langenbecks Arch Surg 2020; 406:971-980. [PMID: 32803330 PMCID: PMC8208906 DOI: 10.1007/s00423-020-01957-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE In most cases, traditional techniques to perform an anastomosis following gastrointestinal resections lead to successful healing. However, despite focused research in the field, in certain high-risk situations leakage rates remain almost unchanged. Here, additional techniques may help the surgeon to protect the anastomosis and prevent leakage. We give an overview of some of the latest developments on experimental and clinical techniques for induction of anastomotic healing. METHODS We performed a review of the current literature on approaches to improve anastomotic healing. RESULTS Many promising approaches with a high clinical potential are in the developmental pipeline. Highly experimental approaches like inhibition of matrix metalloproteinases, stem cell therapy, hyperbaric oxygen therapy, induction of the hypoxic adaptive response, and the administration of growth factors are still in the preclinical phase. Other more clinical developments aim to strengthen the anastomotic suture line mechanically while shielding it from the influence of the microbiome. Among them are gluing, seaming the staple line, attachment of laminar biomaterials, and temporary intraluminal tubes. In addition, individualized bowel preparation, selectively reducing certain detrimental microbial populations could become the next stage of bowel preparation. Compression anastomoses are evolving as an equivalent technique additional to established hand-sewn and stapled anastomoses. Fluorescence angiography and flexible endoscopy could complement intraoperative quality control additionally to the air leak tests. Virtual ileostomy is a concept to prepare the bowel for the easy formation of a stoma in case of leakage. CONCLUSION A variety of promising diagnostic and prophylactic measures that may support the surgeon in identifying high-risk anastomoses and support them according to their potential deficits is currently in development.
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Affiliation(s)
- Stefan Reischl
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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Postoperative administration of non-steroidal anti-inflammatory drugs in colorectal cancer surgery does not increase anastomotic leak rate; A systematic review and meta-analysis. Eur J Surg Oncol 2020; 46:2167-2173. [PMID: 32792221 DOI: 10.1016/j.ejso.2020.07.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/15/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Evidence on the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on anastomotic leak (AL) rate after colorectal surgery is conflicting. Effects of NSAIDs might depend on the underlying disease. This meta-analysis aimed to review the effect of NSAIDs on AL rate in a homogeneous colorectal cancer patient population. METHODS A systematic literature search using MEDLINE and EMBASE database was performed for studies with AL as primary outcome comparing NSAID use in the early postoperative phase with no NSAID administration in colorectal cancer patients undergoing surgical resection. RESULTS Nine studies including 10,868 patients met the inclusion criteria. The majority, 7689 patients (70.7%) underwent low anterior resection and 3050 patients (28.1%) underwent colonic resection. The pooled incidence of AL was 8.6% (95%CI 7.0-10.0). Overall AL rate after colorectal cancer surgery was not increased in patients using NSAIDs for postoperative analgesia compared to non-users (p = 0.34, RR 1.23; 95%CI 0.81-1.86). This effect remained non-significant after stratification for low anterior resections (p = 0.07). Stratification for colonic resections could not be performed because AL results for this subgroup were not reported separately. Neither non-selective NSAID use nor COX-2 selective NSAID use caused an increased AL rate (p = 0.19, p = 0.26). The results were robust throughout sensitivity analyses. CONCLUSION Use of NSAIDs in cohorts with patients undergoing surgical resection for colorectal cancer does not increase overall AL rate. Since results were robust throughout several subgroup and sensitivity analyses, prescription of NSAIDs after colorectal cancer surgery seems safe.
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Jago CA, Nguyen DB, Flaxman TE, Singh SS. Bowel surgery for endometriosis: A practical look at short- and long-term complications. Best Pract Res Clin Obstet Gynaecol 2020; 71:144-160. [PMID: 32680784 DOI: 10.1016/j.bpobgyn.2020.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023]
Abstract
Endometriosis involving the bowel requires a thorough evaluation prior to deciding upon surgical treatment. Patient symptoms, treatment goals, extent and location of disease, surgeon experience, and anticipated risks all play a part in the preoperative decision-making process. Short- and long-term complications after bowel surgery for endometriosis are the focus of this article. Unfortunately, the literature to date has inherent limitations that prevent generalizability. Most studies are retrospective or prospective single-center case series. Publication bias is unavoidable with mainly large volume experts sharing their experience. As a result, there is a need for high-quality prospective studies that standardize inclusion criteria and outcome measures among various centers with an aim to present long-term outcomes. In the meantime, care for those with endometriosis involving the bowel requires a thorough preoperative plan to minimize risks and a need for early diagnosis and management of complications unique to bowel surgery.
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Affiliation(s)
- Caitlin Anne Jago
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada
| | - Dong Bach Nguyen
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada
| | - Teresa E Flaxman
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada; Ottawa Hospital Research Institute, Department of Clinical Epidemiology, 1053 Carling Ave, K1Y 4E9, Ottawa ON Canada
| | - Sukhbir S Singh
- Minimally Invasive Gynecology Research Group, Department of Ob/Gyn and Newborn Care, University of Ottawa & the Ottawa Hospital, 501 Smyth Rd, K1H 8L6, Ottawa ON Canada; Ottawa Hospital Research Institute, Department of Clinical Epidemiology, 1053 Carling Ave, K1Y 4E9, Ottawa ON Canada.
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A serendipitous voyage in the field of nutrition and metabolism in health and disease: a translational adventure. Eur J Clin Nutr 2020; 74:1375-1388. [PMID: 32060384 DOI: 10.1038/s41430-020-0584-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 01/29/2020] [Accepted: 01/31/2020] [Indexed: 11/08/2022]
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