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Huang L, Zhang T, Wang K, Chang B, Fu D, Chen X. Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients. Pain Ther 2024; 13:745-766. [PMID: 38836984 PMCID: PMC11254899 DOI: 10.1007/s40122-024-00619-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.
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Affiliation(s)
- Li Huang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Tianhao Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Kaixin Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Bingcheng Chang
- The Second Affiliated Hospital of Guizhou, University of Traditional Chinese Medicine, Guiyang, 550003, China
| | - Daan Fu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Ministry of Education, Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Wuhan, China.
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Ministry of Education, Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Wuhan, China.
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Pelkonen RM, Frykholm P, Enlund G, Lilja HE. Swedish registry study showed that 50% of paediatric operations were performed in university hospitals and mortality was low. Acta Paediatr 2024; 113:550-556. [PMID: 38013512 DOI: 10.1111/apa.17049] [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: 10/02/2023] [Revised: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Abstract
AIM To investigate the distribution of paediatric surgery in various hospitals and to study postoperative risk factors of mortality. METHODS Retrospective registry-based cohort study of children aged 0-14 years undergoing surgery from 2017 to 2021. Data were extracted from the Swedish Perioperative Registry. A mixed logistic regression was applied for the all-risk mortality analysis. RESULTS A total of 126 539 cases were identified, 50% in university, 36% in county and 14% in district hospitals. The dominating operations were appendectomy in 6667, orchidopexy in 5287, inguinal hernia repair in 4200 and gastrostomy in 1152 children. Among children under 1 year of age or American Society of Anesthesiologists Physical Status classification (ASA-PS-Class) 3-5, the majority underwent surgery in university hospitals. The 30-day mortality in university hospitals was 0.5% and in county hospitals 0%. The proportion of emergency surgery was similar in university and county hospitals. Independent risk factors of mortality were being under 1 year of age, ASA-PS-class 4-5, emergency surgery and surgery at university hospitals. CONCLUSION Half of all operations in children were performed in university hospitals, with low postoperative mortality despite effective centralisation of high risk patients <1 year of age or ASA-PS-Class 3-5.
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Affiliation(s)
- Ruut-Maria Pelkonen
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Peter Frykholm
- Department of Anaesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Gunnar Enlund
- Department of Anaesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
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Zhou Y, Cao L, Yang Y, Gao Y, Li Y, Wang B, Pan B, Huang J, Guo W. Is OPRM1 genotype a valuable predictor of VAS in patients undergoing laparoscopic radical resection of colorectal cancer with fentanyl? BMC Anesthesiol 2023; 23:173. [PMID: 37217861 DOI: 10.1186/s12871-023-02120-1] [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: 01/09/2023] [Accepted: 04/30/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE This study was conducted to examine the association between the A118G polymorphism of the OPRM1 gene and the risk of increased VAS scores in patients with colorectal cancer who underwent laparoscopic radical resection for which fentanyl was used. METHODS The OPRM1 A118G genotype in subjects were detected. The relationship between the A118G polymorphism of the OPRM1 gene and increased Visual Analogue Scale (VAS) scores throughout the perioperative period was explored. A total of 101 patients receiving fentanyl anesthesia undergoing laparoscopic radical resection of colon tumors at Zhongshan Hospital, Fudan University between July 2018 and December 2020 were investigated in the present study. The relative risk between the A118G polymorphism of the OPRM1 gene and VAS ≥ 4 in the PACU was estimated using the adjusted effect relationship diagram, baseline characteristic analysis, and multiple logistic regression analysis. The relationship between the A118G polymorphism of the OPRM1 gene and VAS in the PACU, as well as perioperative fentanyl usage, was examined after confounders were adjusted. RESULTS Subjects with OPRM1 A118G wild gene A were less sensitive to fentanyl, which was a risk factor for PACU VAS ≥ 4. Before the model was adjusted, the odds ratio (OR) was 14.73 (P = 0.001). After adjusting for age, sex, weight, height, and the duration of surgery, the OR increased to 16.55 (P = 0.001). When adjusting for age, sex, weight, height, surgery duration, COMT Val158Met gene polymorphism, CYP3A4 *1G gene polymorphism, and CYP3A5 *3gene polymorphism, the OR was 19.94 (P = 0.002). Moreover, OPRM1 A118G wild type gene A was found to be a risk factor for increased dosage of fentanyl in the PACU. Before the model was adjusted, the OR reached 16.90 (P = 0.0132). After adjusting for age, sex, body weight, intraoperative fentanyl dosage, surgery duration, and height, the OR was 13.81, (P = 0.0438). When adjusting for age, sex, weight, height, intraoperative fentanyl dosage, surgery duration, COMT Val158Met gene polymorphism, CYP3A4 *1G gene polymorphism, and CYP3A5 *3 gene polymorphism, the OR reached 15.23, (P = 0.0205). CONCLUSION The A118G polymorphism of the OPRM1 gene carrying wild gene A was a risk factor for VAS ≥ 4 in the PACU. Moreover, it is a risk factor for increased dosage of fentanyl in the PACU.
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Affiliation(s)
- Yan Zhou
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Lei Cao
- Department of Pharmacy, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Yihui Yang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Yaoyi Gao
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Yihao Li
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Beili Wang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Baishen Pan
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China
| | - Jian Huang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
| | - Wei Guo
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, 111 Yi Xue Yuan Road, Shanghai, 200032, People's Republic of China.
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Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going? Curr Oncol 2023; 30:3111-3137. [PMID: 36975449 PMCID: PMC10047700 DOI: 10.3390/curroncol30030236] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Abstract
Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.
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Holmström B, Enlund G, Spetz P, Frostell C. The Swedish Perioperative Register: Description, validation of data mapping and utility. Acta Anaesthesiol Scand 2023; 67:233-239. [PMID: 36424870 PMCID: PMC10108284 DOI: 10.1111/aas.14174] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/10/2022] [Accepted: 11/17/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Since 2013 surgical units in Sweden have reported procedures to the national Swedish Perioperative Register (SPOR). More than four million cases have been documented. Data consist of patient ID, type of surgery, diagnoses, time stamps during the perioperative process (from the decision to operate to the time of discharge from the postoperative recovery area) and quality measures. This article aims to describe SPOR and validate data mapping. Also, we wished to illustrate the utility of the SPOR in assessing variations in national surgical capacity during the COVID-19 pandemia years 2020-2021. METHODS After a detailed description of SPOR, we report on the validation of data performed by comparing data from local databases with data stored in the central SPOR database, assessing missing values and accuracy. Effects of the pandemic on surgical capacity were described by developing an index, based on the number of performed surgical procedures per week during four production weeks in January 2020. Subsequent weeks were then compared with this baseline. RESULTS The validation effort demonstrated nearly 100% data accuracy for the number and type of surgical procedures between local and central data. Missing data was a problem for some parameters. The number of performed surgical procedures decreased dramatically from week 11 in 2020 compared with normal production on a national basis, mainly impairing elective surgery. DISCUSSION Data validation revealed good agreement between local and central databases. The changes in national surgical capacity during the pandemic were illustrated by an index based on the reported surgical production.
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Affiliation(s)
- Björn Holmström
- Department of Medical Technology, Development and Management, Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Enlund
- Department of Anaesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Peter Spetz
- Department of Anaesthesia and Intensive Care, Mälarsjukhuset, Eskilstuna, Sweden
| | - Claes Frostell
- Department of Anaesthesia and Intensive Care, Karolinska Institute at Danderyd Hospital, Stockholm, Sweden
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Rama NJG, Lages MCC, Guarino MPS, Lourenço Ó, Motta Lima PC, Parente D, Silva CSG, Castro R, Bento A, Rocha A, Castro-Pocas F, Pimentel J. Usefulness of serum C-reactive protein and calprotectin for the early detection of colorectal anastomotic leakage: A prospective observational study. World J Gastroenterol 2022; 28:2758-2774. [PMID: 35979163 PMCID: PMC9260864 DOI: 10.3748/wjg.v28.i24.2758] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/22/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL) is one of the most dreaded complications after colorectal surgery, with an incidence that can be as high as 27%. This event is associated with increased morbidity and mortality; therefore, its early diagnosis is crucial to reduce clinical consequences and costs. Some biomarkers have been suggested as laboratory tools for the diagnosis of CAL.
AIM To assess the usefulness of plasma C-reactive protein (CRP) and calprotectin (CLP) as early predictors of CAL.
METHODS A prospective monocentric observational study was conducted including patients who underwent colorectal resection with anastomosis, from March 2017 to August 2019. Patients were divided into three groups: G1 – no complications; G2 – complications not related to CAL; and G3 – CAL. Five biomarkers were measured and analyzed in the first 5 postoperative days (PODs), namely white blood cell (WBC) count, eosinophil cell count (ECC), CRP, CLP, and procalcitonin (PCT). Clinical criteria, such as abdominal pain and clinical condition, were also assessed. The correlation between biomarkers and CAL was evaluated. Receiver operating characteristic (ROC) curve analysis was used to compare the accuracy of these biomarkers as predictors of CAL, and the area under the ROC curve (AUROC), specificity, sensitivity, positive predictive value, and negative predictive value (NPV) during this period were estimated.
RESULTS In total, 25 of 396 patients developed CAL (6.3%), and the mean time for this diagnosis was 9.0 ± 6.8 d. Some operative characteristics, such as surgical approach, blood loss, intraoperative complications, and duration of the procedure, were notably related to the development of CAL. The length of hospital stay was markedly higher in the group that developed CAL compared with the group with complications other than CAL and the group with no complications (median of 21 d vs 13 d and 7 d respectively; P < 0.001). For abdominal pain, the best predictive performance was on POD4 and POD5, with the largest AUROC of 0.84 on POD4. Worsening of the clinical condition was associated with the diagnosis of CAL, presenting a higher predictive effect on POD5, with an AUROC of 0.9. WBC and ECC showed better predictive effects on POD5 (AUROC = 0.62 and 0.7, respectively). Those markers also presented a high NPV (94%-98%). PCT had the best predictive effect on POD5 (AUROC = 0.61), although it presented low accuracy. However, this biomarker revealed a high NPV on POD3, POD4, and POD5 (96%, 95%, and 96%, respectively). The mean CRP value on POD5 was significantly higher in the group that developed CAL compared with the group without complications (195.5 ± 139.9 mg/L vs 59.5 ± 43.4 mg/L; P < 0.00001). On POD5, CRP had a NPV of 98%. The mean CLP value on POD3 was significantly higher in G3 compared with G1 (5.26 ± 3.58 μg/mL vs 11.52 ± 6.81 μg/mL; P < 0.00005). On POD3, the combination of CLP and CRP values showed a high diagnostic accuracy (AUROC = 0.82), providing a 5.2 d reduction in the time to CAL diagnosis.
CONCLUSION CRP and CLP are moderate predictors of CAL. However, the combination of these biomarkers presents an increased diagnostic accuracy, potentially decreasing the time to CAL diagnosis.
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Affiliation(s)
- Nuno J G Rama
- Colorectal Surgical Division, Leiria Hospital Centre, Leiria 2410-021, Portugal
- Abel Salazar Biomedical Institute (ICBAS), University of Oporto, Oporto 4099-002, Portugal
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Marlene C C Lages
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Maria Pedro S Guarino
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Óscar Lourenço
- Faculty of Economics, CeBER, University of Coimbra, Coimbra 3000-137, Portugal
| | | | - Diana Parente
- Colorectal Surgical Division, Leiria Hospital Centre, Leiria 2410-021, Portugal
| | - Cândida S G Silva
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Ricardo Castro
- Clinical Pathology Division, Leiria Hospital Centre, Leiria 2410-541, Portugal
| | - Ana Bento
- Clinical Pathology Division, Leiria Hospital Centre, Leiria 2410-541, Portugal
| | - Anabela Rocha
- Abel Salazar Biomedical Institute (ICBAS), University of Oporto, Oporto 4099-002, Portugal
- Surgical Division, Oporto Hospital Centre, Oporto 4099-001, Portugal
| | - Fernando Castro-Pocas
- Abel Salazar Biomedical Institute (ICBAS), University of Oporto, Oporto 4099-002, Portugal
- Department of Gastroenterology, Santo António Hospital, Porto Hospital Center, Porto 4099-001, Portugal
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto 4099-001, Portugal
| | - João Pimentel
- Faculty of Medicine, University of Coimbra, Coimbra 3004-531, Portugal
- Surgical Division, Montes Claros Hospital, Coimbra 3030-320, Portugal
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