Surgical management of complications of steroid therapy

Corticosteroid Therapy and Vascular Complications in Patients Undergoing Transcatheter Aortic Valve Replacement: A Meta-analysis With Meta-regression

Background

Corticosteroid use is associated with vascular fragility, prolonged wound healing, and infections. Therefore, we sought to compare outcomes between patients with aortic stenosis undergoing transcatheter aortic valve replacement who were using corticosteroids versus those who were not.

Methods

This is a study-level meta-analysis and meta-regression of observational studies. The primary end points of this study were rates of vascular complication (both major and minor), life-threatening bleeding, and 30-day mortality. Secondary end points included acute kidney injury rates, annular rupture, cardiac tamponade, closure device failure, coronary obstruction, periprocedural myocardial infarction, permanent pacemaker implantation, stroke, and specific vascular complications with its complementary therapy.

Results

Across the studies, patients were slightly predominantly female, older, and had a mean left ventricular ejection fraction of more than 50% with an intermediate Logistic EuroScore II. Significant differences were observed in the vascular complication rates between patients on corticosteroids and those who were corticosteroid-free (relative risk, 0.63; 95% CI, 0.35-0.90; P <.001), driven primarily by arterial occlusion, surgery, balloon angioplasty, and stenting (relative risk, 0.63; 95% CI, 0.32-0.93; P <.05). There was no difference in the 30-day mortality. No differences were seen in the length of corticosteroid therapies. For the secondary outcomes, there was an increased risk of annular rupture and cardiac tamponade in patients taking corticosteroids.

Conclusions

In conclusion, this is the first meta-analysis with meta-regression that showed a higher risk for vascular complications and life-threatening bleeding in patients on corticosteroid therapy undergoing transcatheter aortic valve replacement, despite no increase in the risk of 30-day mortality.

Effect of Immunosuppressive Therapy on Clinical Outcomes for Patients With Aortic Stenosis Following Transcatheter Aortic Valve Implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is an established treatment for symptomatic patients with severe aortic stenosis (AS). Sometimes patients with severe AS taking immunosuppressants are encountered. The effect of immunosuppressive therapy on clinical outcomes in patients with AS following TAVI were investigated.

METHODS AND RESULTS

In total, 282 consecutive patients with severe AS who underwent transfemoral TAVI from January 2016 to December 2018 at St. Marianna University School of Medicine were reviewed. They were divided into 2 groups: the immunosuppressants group (IM group) in which patients continually used immunosuppressive drugs (n=22) and the non-immunosuppressants group (non-IM group) (n=260). The composite endpoints of a major adverse cardiovascular and cerebrovascular event (MACCE) defined as non-lethal myocardial infarction, unstable angina pectoris, heart failure requiring hospitalization, stroke, and cardiovascular death were evaluated. There were no differences in the incidence of vascular access complications (32% vs. 20%, P=0.143) and the rate of procedure success (100% vs. 93%, P=0.377) between the IM and non-IM groups. During the median follow-up period of 567 (16-1,312) days after the TAVI procedure, there were no significant differences between the IM and non-IM groups in the incidence of infectious complications (14% vs. 9%, P=0.442) or MACCE (18% vs. 20%, respectively; P=0.845).

CONCLUSIONS

The use of IM after TAVI is not associated with increased vascular access complications or mid-term MACCE in patients with severe AS treated with TAVI.

Healing septal perforations by secondary intention using acellular dermis as a bioscaffold

OBJECTIVE

Several techniques are described in the literature for nasal septal perforation repair. Most of these involve interposition grafts in conjunction with local pedicled mucosal flaps. The following article describes our experience using acellular dermis as a bioscaffold to support the regrowth of nasal septal mucosa by secondary intention.

METHODS

Retrospective chart review of all patients who underwent repair of nasal septal perforations by the senior author using acellular dermis placed between the 2 sides of the perforation and covered with silastic splints to allow for mucosalization.

RESULTS

Thirteen patients underwent nasal septal perforation repair using this technique. All perforations repaired were under 2 cm in greatest dimension. Two-thirds of patients had complete closure of the perforation upon initial use of bioscaffolding technique. The remaining third achieved near-total closure with bioscaffolding technique and were able to be completely closed with a single additional procedure.

CONCLUSIONS

Acellular dermis offers an alternative to most currently described complex flaps. The method can be used in patients with defects less than 2 cm, but initial data suggest caution when using in those with wound healing impediments. This technique is also an excellent choice for patients with multiple small septal perforations.

Corticosteroids and wound healing: clinical considerations in the perioperative period

BACKGROUND

Determining whether systemic corticosteroids impair wound healing is a clinically relevant topic that has important management implications.

METHODS

We reviewed literature on the effects of corticosteroids on wound healing from animal and human studies searching MEDLINE from 1949 to 2011.

RESULTS

Some animal studies show a 30% reduction in wound tensile strength with perioperative corticosteroids at 15 to 40 mg/kg/day. The preponderance of human literature found that high-dose corticosteroid administration for <10 days has no clinically important effect on wound healing. In patients taking chronic corticosteroids for at least 30 days before surgery, their rates of wound complications may be increased 2 to 5 times compared with those not taking corticosteroids. Complication rates may vary depending on dose and duration of steroid use, comorbidities, and types of surgery.

CONCLUSIONS

Acute, high-dose systemic corticosteroid use likely has no clinically significant effect on wound healing, whereas chronic systemic steroids may impair wound healing in susceptible individuals.

Influence of local or systemic corticosteroids on skin wound healing resistance

PURPOSE: To compare the resistance of skin wound healing of mice submitted to local or systemic hydrocortisone administration, in different postoperative periods. METHODS: An incision and suture was performed on the thoracic skin of 130 male mice: Group 1 (n = 10) resistance of the integer skin; Group 2 (n = 30) submitted only to skin incision and suture; Group 3 (n = 30) skin incision and suture followed by administration of saline fluid; Group 4 (n = 30) skin incision and suture followed by administration of local hydrocortisone; Group 5 (n = 30) skin incision and suture followed by administration of systemic hydrocortisone. The resistance of the wound healing and the weight of the animals were studied on the seventh, 14th and 21st postoperative days. Histological examination was also performed. RESULTS: The mice that received corticoid (groups 4 and 5) presented significant decreasing on their weight (p = 0.02). The Groups 3, 4 and 5 showed lower scar resistance than Group 2 on the seventh postoperative day (p < 0.05). On the 14th and 21st days, there was no difference on the skin would healing resistance (p > 0.05). CONCLUSION: Administration of hydrocortisone in mice is responsible for weight decreasing and reduction of the skin wound healing resistance during the first postoperative week.

Anti-inflammatory efficiency of levobupivacaine in an experimental colitis model

AIM: To investigate the efficiency of levobupivacaine in treating experimentally induced colitis in rats.

METHODS: Colitis was induced by trinitrobenzene sulfonic acid and ethanol in 30 rats under general anesthesia, and 10 rats were used as a sham group. Subsequent to induction of colitis, rats were divided into three groups; budesonide group received 0.1 mg/kg budesonide, levobupivacaine group received 10 mg/kg levobupivacaine and saline group received 1 mL saline solution via rectal route for 7 d. In the sham group, only routine rectal catheterization was performed without use of any material. At the end of 7 d, laparotomy and total colectomy were performed for histopathological examination in all rats and blood samples were drawn for measurement of tumor necrosis factor (TNF)-α and interleukin (IL)-6 following cardiac puncture. Macroscopic and microscopic evaluations of the specimens were performed by a pathologist blinded to group assignment of the rats.

RESULTS: Weight loss (P = 0.016) and macroscopic examination scores (P = 0.001) were significantly higher in saline group than others. Histopathological scoring was comparable between all colitis groups (P = 0.350). There was no significant difference in TNF-α levels and IL-6 levels (P = 0.150).

CONCLUSION: The significant improvement in macroscopic scores suggests that levobupivacaine may have topical anti-inflammatory effects in an experimental colitis model; however, this finding was not supported by microscopic findings.

New and improved glucocorticoid receptor ligands

The therapeutic and prophylactic use of glucocorticoids is widespread due to their powerful anti-inflammatory, antiproliferative and immunomodulatory activity. However, long-term use of these drugs can result in severe dose-limiting side effects. One of the most critical and debilitating side effects is osteoporosis, which leads to increased risk of fractures. Glucocorticoids damage bone through several different mechanisms. The search for novel glucocorticoids that have reduced side effects in bone and other tissues is being driven by the identification of new mechanisms of action of the glucocorticoid receptor. This may facilitate the detection of new, safer therapies with efficacies equivalent to currently prescribed steroids.

The search for safer glucocorticoid receptor ligands

Steroidal glucocorticoids are commonly used due to their powerful antiinflammatory activity. However, despite their excellent efficacy, severe side effects frequently limit the use of these drugs. The search for novel glucocorticoids with reduced side effects has been intensified by the discovery of new molecular details regarding the function of the glucocorticoid receptor. These new insights may pave the way for novel, safer therapies that retain the efficacy of currently prescribed steroids.

Efeito da hidrocortisona sobre a resistência cicatricial da pele em camundongos

OBJETIVO: O efeito da corticoterapia sobre a cicatrização de feridas cirúrgicas vem apresentando resultados conflitantes na literatura, principalmente quando usada por tempo prolongado. O objetivo do presente trabalho foi comparar a resistência cicatricial da pele de camundongos submetidos à administração de hidrocortisona, em distintos períodos pós-operatórios. MÉTODO: Foram estudados 150 camundongos machos submetidos à incisão e sutura da pele dorsal, divididos em cinco grupos. No Grupo 1 (n=6) avaliou-se apenas a resistência da pele íntegra. Nos demais grupos (n = 36) realizaram-se incisão e sutura na pele, sendo que o Grupo 2 (controle) submeteu-se apenas à operação, enquanto o Grupo 3 recebeu, ainda, solução salina a 0,9% e os Grupos 4 e 5 receberam 10mg/kg/dia de hidrocortisona local e sistêmica, respectivamente. Avaliaram-se a resistência cicatricial e a variação ponderal nos sétimo e 21º dias pós-operatórios. RESULTADOS: Os camundongos que receberam corticóide, Gupos 4 e 5, apresentaram decréscimo ponderal significativo (p < 0,02). Quanto à resistência cicatricial da pele, os Gupos 3, 4 e 5 apresentaram valor inferior ao Grupo 2 no sétimo dia pós-operatório (p < 0,02). No 21º dia, a queda foi observada apenas no grupo submetido à solução salina (p < 0,05). CONCLUSÃO: Os resultados indicam uma diminuição da resistência cicatricial apenas nos camundongos tratados com corticóide em intervalos menores de tratamento.

Effect of sodium carboxymethylcellulose and methylprednisolone on the healing of jejunal anastomoses in rats

Sodium carboxymethylcellulose (SCMC) has been effective in reducing adhesion formation and corticosteroids reduce the inflammatory process. The objective of this study was to define the intraperitoneal (ip) effects of SCMC combined with intramuscular (im) methylprednisolone on peritoneal adhesion formation and on jejunal anastomosis healing in rats. Twenty Wistar rats (200-350 g) were divided into four groups (N = 5): groups I and III (controls) 5 and 21 days of treatment before sacrifice, respectively; groups II and IV (experimental groups) 5 and 21 days of treatment, respectively. SCMC (1%) was infused into the abdominal cavity and methylprednisolone (10 mg kg-1 day-1) was injected im daily from the day before surgery for animals of groups II and IV. All rats were submitted to a jejunal anastomosis. Sections of the anastomosis were prepared for routine histopathological analysis. The abdominal adhesion of group IV was less intense when compared with group III (P<0.0008). Anastomotic resistance was higher in groups II and IV when compared with groups I and III, respectively (P<0.05). There was no histological difference between groups I and II (exuberant granulation tissue on the serosal surface). Group III presented little peritoneal fibrinous tissue, with numerous thick collagen fibers. Group IV presented extensive although immature young fibrous tissue with rare thick collagen fibers. Sodium carboxymethylcellulose combined with corticosteroids seemed to diminish peritoneal adhesion but did not reduce anastomotic resistance.

THE PIG AS A MODEL FOR HUMAN WOUND HEALING

The medical literature describes numerous in vitro and in vivo wound-healing models. The selection of an animal model depends on a number of factors including availability, cost, ease of handling, investigator familiarity, and anatomical/functional similarity to humans. Small mammals are frequently used for wound healing studies, however, these mammals differ from humans in a number of anatomical and physiological ways. Anatomically and physiologically, pig skin is more similar to human skin. The many similarities between man and pig would lead one to believe that the pig should make an excellent animal model for human wound healing. The purpose of this paper is to review the existing literature for evidence of this supposition and determine how well the various models correlate to human wound healing. Studies of wound dressings, topical antimicrobials, and growth factors are examined. Over 180 articles were utilized for this comparative review. Our conclusion is that the porcine model is an excellent tool for the evaluation of therapeutic agents destined for use in human wounds.

Sigmoid diverticular perforation in neurosurgical patients receiving high-dose corticosteroids

Perforation of colonic diverticula is a complication of corticosteroid use that has not been described in the neurosurgical literature. Between 1987 and 1992, 719 patients who underwent surgery for primary and metastatic brain and spinal tumors of the central nervous system received 2246 to 4936 mg of methylprednisolone given over at least 7 days. Five patients in this group (all men, ages 50-69 yr) experienced a sigmoid diverticular perforation at a mean dose of 3947 mg of methylprednisolone (range, 2240-6160 mg). Of these five, two had a known history of diverticular disease. In contrast, during this same period, 3749 patients who underwent neurosurgical procedures for non-neoplastic conditions did not receive corticosteroids and experienced no colonic perforations. All five patients with colonic perforations presented with abdominal pain and had free intraperitoneal air that was revealed on radiographs of the abdomen. Perforation of a sigmoid diverticulum was confirmed in all five at exploratory laparotomy. Four patients had good outcomes, and one died. We conclude the following: 1) patients over age 50 who receive high-dose corticosteroids are at risk for sigmoid colonic perforation, and these medications should be used with caution in such patients; 2) if possible, lower total doses of perioperative corticosteroids should be used in patients with known diverticular disease; and 3) because corticosteroids mask many of the inflammatory signs of perforation, this diagnosis should be considered in any patient with abdominal discomfort, fever of unknown origin, or unexplained leukocytosis.

Management of the dental patient receiving corticosteroid medications

Patients who have undergone therapy with glucocorticoids present unique problems for the dentist. Persons currently receiving steroid therapy have altered responses to infection and wound healing. More important, many patients who are taking or have taken glucocorticoids have a high risk of developing acute adrenal insufficiency when placed in a stressful situation. When treating patients with a history of glucocorticoid therapy, one must obtain precise information from the medical history to determine the relative risk of pituitary-adrenal suppression. If the patient is at risk, the dentist must determine the need for the following prophylactic measures: (1) systemic antibiotic therapy, (2) anxiety control, and (3) increased administration of glucocorticoids (steroid prep). If a patient experiences adrenal crisis, the dentist must be capable of interpreting the signs and administering appropriate therapy.

Cerebromeningitis in immunosuppressed recipients of renal allografts

The experience with cerebromeningitis in recipients of 769 renal allografts occurring over a 20-year period has been reviewed. Eighteen patients developed this complication; an incidence of 2.7%. Clinical manifestations were often subtle, although fever occurred almost universally. Primary risk factors included diabetes mellitus, use of high dose steroids both as maintenance immunosuppression and as treatment for acute rejection, and coincident infections or complications. The responsible organisms were fungi; the overall mortality rate 44%. By recognizing individual patient types who are at potential high risk for this complication, earlier diagnosis and more prompt and aggressive therapy has diminished the mortality dramatically in the last several years.

Infection in the renal transplant recipient

The incidence of infection in the renal transplant patient is directly related to the net immunosuppressive effect achieved and the duration of time over which this therapy is administered. A second major factor in the causation of infections in this population is the nosocomial hazards to which these patients are exposed, ranging from invasive instrumentation to environmental contamination with Aspergillus species, Legionella pneumophila, Pseudomonas aeruginosa and other microbial pathogens. Careful surveillance is necessary to identify and eliminate such nosocomial sources of infection. The major types of infection observed can be categorized according to the time period post-transplant in which they occur: postsurgical bacterial infection in the first month after transplantation; opportunistic infection, with cytomegalovirus playing a major role, and transplant pyelonephritis in the period one to four months post-transplant; and a mixture of conventional and opportunistic infections in the last post-transplant period. Conventional infection in this late period occurs primarily in patients with good renal function who are receiving minimal immunosuppressive therapy; opportunistic infection occurs primarily in patients with poor renal function who are receiving higher levels of immunosuppression.

Alimentary tract complications after renal transplantation

A computer analysis of post renal transplantation gastrointestinal problems was performed to identify important associated clinical factors. Thirty-seven per cent of all transplant recipients developed one or more significant problems. Hemorrhage, nondiverticular intestinal perforation, and esophagitis occurred most frequently in hospitalized patients. Pancreatitis, diverticulitis, and gastroduodenal perforation occurred characteristically in long-term survivors with well functioning allografts. Eleven of 32 HLA identical recipients treated with maintenance corticosteroids during stable kidney function developed gastrointestinal disease while only one of 13 HLA identical recipients not given maintenance steroids developed a problem, which strongly suggests a causal role for steroids in the development of late complications. The association of preexisting peptic ulcer and diverticular disease with hemorrhage and perforation supports previous recommendations that documented peptic ulcer disease or diverticulitis should be corrected surgically prior to transplantation.