1
|
Etemad SA, Poh MM. Enhanced Recovery After Gender-Affirming Surgery. Aesthet Surg J 2024; 44:S3-S14. [PMID: 39147383 DOI: 10.1093/asj/sjae082] [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] [Indexed: 08/17/2024] Open
Abstract
The adoption of enhanced recovery after surgery (ERAS) protocols in multiple surgical disciplines has revolutionized perioperative care, demonstrating reduced complications and shorter hospital stays across surgical specialties. ERAS protocols have increasingly been incorporated in plastic surgery, yet a notable gap in the literature on ERAS for gender-affirming surgery (GAS) still exists. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies on ERAS protocols in GAS. The aim of this review was to assess the current status of ERAS adoption in GAS, evaluate its impact on perioperative care, and provide recommendations for future research and clinical practice. While there is an overall scarcity of evidence-based ERAS protocols across GAS, published studies on the application of ERAS in GAS have demonstrated promising early outcomes and illustrate an area for further investigation and innovation in plastic surgery. LEVEL OF EVIDENCE: 5
Collapse
|
2
|
Laconi G, Coppens S, Roofthooft E, Van De Velde M. High dose glucocorticoids for treatment of postoperative pain: A systematic review of the literature and meta-analysis. J Clin Anesth 2024; 93:111352. [PMID: 38091865 DOI: 10.1016/j.jclinane.2023.111352] [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: 04/27/2023] [Revised: 10/30/2023] [Accepted: 11/22/2023] [Indexed: 01/14/2024]
Abstract
STUDY OBJECTIVE Glucocorticoids as a component of multimodal analgesia have been studied for many years and their post-operative analgesic effects appear to be dose-dependent. We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the evidence of peri-operative high dose corticosteroid therapy in comparison to placebo (placebo drug) or control group (no treatment) for improving the quality of post-operative analgesia as indicated by a reduction of 10 mm in 100 mm Visual Analogue Scale (VAS) or reduction of 1 point in a 0-10 point VAS scale, or a reduction of 1 point in an 11-point Numerical Rating Scale (NRS) score, or reduction of rescue opioid analgesia, in patients undergoing all types of surgery. DESIGN Systematic review of RCTs with meta-analysis. SETTING Acute postoperative pain treatment in non-obese adult population. INTERVENTIONS Perioperative administration of high dose of Dexamethasone (≥ 0,2 mg/Kg or ≥ 15 mg), or a corresponding dose of a systemic glucocorticoid. MEASUREMENTS Primary outcomes were postoperative pain measured in 0-100 mm VAS score at 24 h after surgery upon rest and movement. Secondary outcomes were postoperative pain 0-100 mm VAS score 48 h after surgery, postoperative rescue analgesic requirement, postoperative nausea and vomiting (PONV), relevant adverse events. MAIN RESULTS 47 RCT's were included (3943 patients). The Mean Difference (MD) of 100 mm VAS scores for pain at rest 24 h after surgery was -6.18 mm 95% CI [-8.53, -3.83], at motion -8.86 mm 95% CI [-11.82, -5.89]. Opioid analgesic requirements evaluated in Oral Morphine Equivalents (OME) was -10.00 mg 95% CI [-13.65, -6.34]. PONV events Odds Ratio of 0.29 95%CI [0.24, 0.36]. Major adverse events OR was 0.88 95% CI [0.65, 1.19]. Minor adverse events OR 1.29 95% CI [0.86, 1.92]. CONCLUSION High doses of glucocorticoids are one of the many possible tools available in multimodal postoperative analgesia, possibly reducing opioids consumption and recurrence of PONV but with no relevant effects in terms of reduction of postoperative VAS score. Available data show a safe therapeutic profile, without increase adverse events. PROTOCOL REGISTRATION CRD42020137119.
Collapse
Affiliation(s)
- Giulia Laconi
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy.
| | - Steve Coppens
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium
| | - Eva Roofthooft
- Department of Anesthesia, GZA Hospitals, Antwerp, Belgium and Department of Cardiovascular sciences, KULeuven, Leuven, Belgium
| | - Marc Van De Velde
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium
| |
Collapse
|
3
|
Aquino NJ, Goobie SM, Staffa SJ, Eastburn E, Ganor O, Jones CT. Implementation of an Enhanced Recovery after Surgery Pathway for Transgender and Gender-Diverse Individuals Undergoing Chest Reconstruction Surgery: An Observational Cohort Study. J Clin Med 2023; 12:7083. [PMID: 38002695 PMCID: PMC10672389 DOI: 10.3390/jcm12227083] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/05/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols are associated with improved clinical outcomes in cisgender breast surgery patients. However, a paucity of research exists regarding transgender and gender-diverse individuals (TGD) in the ERAS framework. The primary objective of this observational cohort study is to describe the implementation of a gender-affirming ERAS protocol and its relationship to hospital length of stay (LOS) in TGD patients following chest reconstruction surgery. The secondary aim is to identify intraoperative predictors of LOS and define variables associated with adverse outcomes. We identified 362 patients in three epochs: a traditional group (n = 144), a partial ERAS implementation group (n = 92), and an ERAS group (n = 126). Exploratory multivariable median regression modeling was performed to identify independent predictors of LOS. We report that the traditional group's median hospital LOS was 1.1 days compared to 0.3 days in the ERAS group. Intraoperative tranexamic acid administration was associated with significantly shorter LOS (p < 0.001), reduced postoperative drainage (p < 0.001), and fewer returns to the operating room within 24 h (p = 0.047). Our data suggest that implementing a multimodal ERAS gender-affirming pathway was associated with improved patient-centered surgical outcomes such as decreased return to the operating room for hematoma evacuation, higher rates of discharge home, and reduced postoperative drainage output.
Collapse
Affiliation(s)
- Nelson J. Aquino
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Susan M. Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Steven J. Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Elizabeth Eastburn
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Oren Ganor
- Center for Gender Surgery, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Cathie T. Jones
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| |
Collapse
|
4
|
Tageza Ilala T, Teku Ayano G, Ahmed Kedir Y, Tamiru Mamo S. Evidence-Based Guideline on the Prevention and Management of Perioperative Pain for Breast Cancer Peoples in a Low-Resource Setting: A Systematic Review Article. Anesthesiol Res Pract 2023; 2023:5668399. [PMID: 37953883 PMCID: PMC10637850 DOI: 10.1155/2023/5668399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/03/2023] [Accepted: 10/24/2023] [Indexed: 11/14/2023] Open
Abstract
Background Breast surgery for breast cancer is associated with significant acute and persistent postoperative pain. Surgery is the primary type of treatment, but up to 60% of breast cancer patients experience persistent pain after surgery, and 40% of them develop acute postmastectomy pain syndrome. Preoperative stress, involvement of lymph nodes while dissecting, and the postoperative psychological state of the patients play vital roles in managing the postoperative pain of the patients. The objective of this study is to develop evidence-based guideline on the prevention and management of perioperative pain for breast cancer surgical patients. Methods An exhaustive literature search was made from PubMed, Cochrane Review, PubMed, Google Scholar, Hinari, and CINAHIL databases that are published from 2012 to 2022 by setting the inclusion and exclusion criteria. After data extraction, filtering was made based on the methodological quality, population data, interventions, and outcome of interest. Finally, one guideline, two meta-analyses, ten systematic reviews, 25 randomized clinical trials and ten observational studies are included in this review, and a conclusion was made based on their level of evidence and grade of recommendation. Results A total of 38 studies were considered in this evaluation. The development of this guideline was based on different studies performed on the diagnosis, risk stratification and risk reduction, prevention of postoperative pain, and treatments of postoperative pain. Conclusion The management of postoperative pain can be categorized as risk assessment, minimizing risk, early diagnosis, and treatment. Early diagnosis is the mainstay to identify and initiate treatment. The perioperative use of a nonpharmacological approach (including preoperative positive inspirational words and positive expectation) as an adjunct to the intraoperative regional anesthetic technique with general anesthesia with proper dosage of the standard pharmacological multimodal regimens is the first-line treatment. For postoperative analgesia, an extended form of intraoperative regional technique, nonpharmacologic technique, and NSAIDs can be used with the opioid-sparing anesthesia technique.
Collapse
Affiliation(s)
- Tajera Tageza Ilala
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Gudeta Teku Ayano
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Yesuf Ahmed Kedir
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Selam Tamiru Mamo
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| |
Collapse
|
5
|
Krepper D, Giesinger JM, Dirven L, Efficace F, Martini C, Thurner AMM, Al-Naesan I, Gross F, Sztankay MJ. Information about missing patient-reported outcome data in breast cancer trials is frequently not documented: a scoping review. J Clin Epidemiol 2023; 162:1-9. [PMID: 37517504 DOI: 10.1016/j.jclinepi.2023.07.012] [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: 05/09/2023] [Revised: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES This review addresses the common problem of missing patient-reported outcome (PRO) data in clinical trials by assessing the current practice of their statistical handling as reported in publications of randomized controlled trials (RCTs) in patients with breast cancer. STUDY DESIGN AND SETTING We searched PubMed to identify RCTs evaluating biomedical treatments in breast cancer patients with at least one PRO endpoint published between January 2019 and February 2022. Two reviewers independently assessed the eligibility of the publications for this scoping review and extracted prespecified information on missing PRO data and related statistical practices. RESULTS Of 1,598 publications identified, 118 trials met the inclusion criteria. Eighty-eight (74.6%) trials reported the extent of missing data, with 11 (9.3%) not containing any missing PRO data. Twenty-one (19.6%) trials explicitly stated the statistical approach for handling missing data, with a preference for single imputation over multiple imputation approaches (57.2%/19.0%). Only six (5.6%) trials reported a sensitivity analysis to examine the extent to the results being affected by changes in assumptions made about missing PRO data. CONCLUSION International efforts to raise awareness of the importance of accurately reporting state-of-the-art handling of missing PRO data are not yet fully reflected in the current literature of breast cancer RCTs.
Collapse
Affiliation(s)
- Daniela Krepper
- Department of Psychiatry, Psychotherapy Psychosomatics and Medical Psychology, University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria.
| | - Johannes Maria Giesinger
- Department of Psychiatry, Psychotherapy Psychosomatics and Medical Psychology, University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Fabio Efficace
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Caroline Martini
- Institute of Psychology, University of Innsbruck, Innsbruck, Austria
| | - Anna Margarete Maria Thurner
- Department of Psychiatry, Psychotherapy Psychosomatics and Medical Psychology, University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| | - Imad Al-Naesan
- Department of Psychiatry, Psychotherapy Psychosomatics and Medical Psychology, University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Gross
- Department of Psychiatry, Psychotherapy Psychosomatics and Medical Psychology, University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| | - Monika Judith Sztankay
- Department of Psychiatry, Psychotherapy Psychosomatics and Medical Psychology, University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
6
|
Wang D, Chen W, Zhang L, Wang Z, Qian Y, Li T, Sun J. Dexamethasone as additive of local infiltration analgesia reduces opioids consumption after simultaneous bilateral total hip or knee arthroplasty: a randomized controlled double-blind trial. J Orthop Surg Res 2023; 18:715. [PMID: 37736729 PMCID: PMC10514997 DOI: 10.1186/s13018-023-04164-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023] Open
Abstract
PURPOSE A randomized controlled double-blind trial was conducted to evaluate the effects of adding dexamethasone to the local infiltration analgesia (LIA) mixture on frequency of patient controlled analgesia (PCA) and opioids consumption after simultaneous bilateral total hip or knee arthroplasty (THA or TKA). METHODS 108 patients who received simultaneous bilateral THA or TKA were randomly divided into dexamethasone group and normal saline (NS) group. The main difference between two groups was whether or not dexamethasone was added to the LIA mixture. The main outcome was the cumulative consumption of opioids within 24 h. The secondary outcome were the total cumulative consumption of opioids during postoperative hospitalization, consumption of opioids drug for rescue analgesia, frequency of PCA, postoperative Visual Analogue Scale (VAS), and complications. RESULTS Cumulative consumption of opioids in the 24 h was similar between two groups (P = 0.17). Total cumulative consumption of opioids in the dexamethasone group during postoperative hospitalization was significantly lower (P = 0.03). No significant difference in the consumption of opioids drug for rescue analgesia between two groups within 24 h, while the frequency of PCA was significantly different (P = 0.04). VAS of dexamethasone group and NS group were similar during postoperative hospitalization, while the incidence of postoperative nausea and vomiting (PONV) in dexamethasone group was lower than that in NS group. CONCLUSIONS Adding dexamethasone to LIA in the simultaneous bilateral THA or TKA can effectively reduce the total cumulative consumption of opioids and the frequency of PCA, as well as reduce the incidence of PONV. Trial Registration The trial has been registered in the Chinese Clinical Trial Registry (Registration Number: ChiCTR2100042551, Date: 23/01/2021).
Collapse
Affiliation(s)
- Dasai Wang
- Orthopedic Center, Nanjing Jiangbei Hospital, Nanjing, 210043, Jiangsu, People's Republic of China
- Department of Orthopedics Surgery, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241000, Anhui, People's Republic of China
| | - Wang Chen
- Department of Orthopedics Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, Heilongjiang, People's Republic of China
| | - Leshu Zhang
- Department of Orthopedics Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, Heilongjiang, People's Republic of China
| | - Zhigang Wang
- Orthopedic Center, Nanjing Jiangbei Hospital, Nanjing, 210043, Jiangsu, People's Republic of China
| | - Yu Qian
- Department of Orthopedics Surgery, Nanjing Drum Tower Hospital Group Suqian Hospital, Suqian, 223800, Jiangsu, People's Republic of China
| | - Tao Li
- Orthopedic Center, Nanjing Jiangbei Hospital, Nanjing, 210043, Jiangsu, People's Republic of China.
| | - Jianning Sun
- Department of Orthopedics Surgery, Nanjing Drum Tower Hospital Group Suqian Hospital, Suqian, 223800, Jiangsu, People's Republic of China.
- Department of Orthopedics Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, People's Republic of China.
| |
Collapse
|
7
|
Skovbye M, Mølgaard J, Rasmussen SM, Sørensen HB, Meyhoff CS, Aasvang EK. The association between vital signs abnormalities during postanaesthesia care unit stay and deterioration in the general ward following major abdominal cancer surgery assessed by continuous wireless monitoring. CRIT CARE RESUSC 2022; 24:330-340. [PMID: 38047011 PMCID: PMC10692640 DOI: 10.51893/2022.4.oa3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Objective: Vital signs abnormalities in the post-anaesthesia care unit (PACU) may identify patients at risk of severe postoperative complications in the general ward, but are sparsely investigated by continuous monitoring. We aimed to assess if the severity of vital signs abnormalities in the PACU was correlated to the duration of severe vital signs abnormalities and serious adverse events (SAEs) in the general ward. Design: Prospective cohort study. Primary exposure was PACU vital signs abnormalities assessed by a standardised PACU recovery score. Participants: Adult patients, aged ≥ 60 years, who underwent major abdominal cancer surgery. Main outcome measures: The duration of severe vital signs abnormalities were assessed by continuous wireless vital signs monitoring and, secondly, by any SAE within the first 96 hours in the general ward. Results: One-hundred patients were included, and 92 patients with a median of 91 hours (interquartile range, 71-95 hours) of vital signs recording were analysed. The maximum vital signs abnormalities in the PACU were not significantly correlated to overall vital signs abnormalities in the general ward (R = 0.13; P = 0.22). Severe circulatory abnormalities in the overall PACU stay and at discharge were significantly correlated to the duration of circulatory vital signs abnormalities on the ward (R = 0.32 [P = 0.00021] and R = 0.26 [P = 0.014], respectively). Seventeen patients (18%) experienced SAEs, without significant association to the PACU stay (area under the receiver operating characteristic [AUROC], 0.59; 95% CI, 0.46-0.73). Conclusion: Vital signs abnormalities in the PACU did not show a tendency towards predicting overall severe vital signs abnormalities or SAEs during the first days in the general ward. Circulatory abnormalities in the PACU showed a tendency towards predicting circulatory complications in the ward.
Collapse
Affiliation(s)
- Magnus Skovbye
- Department of Anaesthesiology, the Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Mølgaard
- Department of Anaesthesiology, the Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Søren M. Rasmussen
- Department of Health Technology, Technical University of Denmark, Kgs Lyngby, Denmark
| | - Helge B.D. Sørensen
- Department of Health Technology, Technical University of Denmark, Kgs Lyngby, Denmark
| | - Christian S. Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Eske K. Aasvang
- Department of Anaesthesiology, the Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
8
|
Lu Y, Xu L, Lin X, Qi X, Xia L, Wang Y. Analysis of the Effect of Fast Recovery Surgery Concept on Perioperative Nursing Care of Patients with Radical Resection of Cervical Cancer and Its Influence on Psychological Status. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:2023159. [PMID: 35983010 PMCID: PMC9381187 DOI: 10.1155/2022/2023159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 11/17/2022]
Abstract
Objective To explore the applied effect of fast-track surgery concept in the perioperative nursing of patients undergoing radical cervical cancer surgery and its influence on mental state. Methods The clinical data of 110 patients undergoing radical cervical cancer surgery in our hospital from May 2015 to May 2017 were retrospectively analyzed, and they were randomly divided into a research group (n = 55) and a reference group (n = 55). The reference group received routine clinical nursing, and the research group received fast-track surgical nursing. Then, we compared their nursing effect and influence on the mental state of patients in the two groups. Results The Karnofsky performance status (KPS) scores of patients in the two groups after intervention were significantly lower than those before the intervention (P < 0.001), and after intervention, patients in the research group had significantly lower KPS scores as compared to patients in the reference group (P < 0.001). There was a significant decrease in the self-rating anxiety scale (SAS) scores and self-rating depression scale (SDS) scores of patients in the two groups after intervention in comparison with before intervention (P < 0.001), and patients in the research group after intervention had significantly lower SAS and SDS scores compared to the reference group (P < 0.001). Patients in the research group spent short time on expelling gas, eating, and getting out of bed as compared to the reference group (P < 0.001); after intervention, compared to patients in the reference group, patients in the research group had significantly higher scores in cognitive function, emotional function, social function, and physical function (P < 0.05). There was no significant difference in IgA, IgM, and IgG levels before intervention (P > 0.05). After intervention, the IgA, IgM, and IgG levels of patients in the two groups were all lower than before intervention, and patients in the research group had significantly higher IgA, IgM, and IgG levels as compared to the reference group (P < 0.001); the complication rate of patients in the research group was significantly lower than that in the reference group (P < 0.05). Conclusion The fast-track surgery concept effectively helps improve the negative emotion of patients, shorten recovery time, improve quality of life, and reduce the impact on immune function in the radical cervical cancer surgery, and it is worthy of promotion and application, with a high safety.
Collapse
Affiliation(s)
- Yun Lu
- Department of Obstetrics and Gynecology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Luxi Xu
- Department of Obstetrics and Gynecology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Xiaoyu Lin
- Department of Pediatrics, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Xueling Qi
- Department of Obstetrics and Gynecology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Ling Xia
- Department of Obstetrics and Gynecology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Yuan Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Jiangnan University, Wuxi, China
| |
Collapse
|
9
|
Awada HN, Steinthorsdottir KJ, Schultz NA, Hillingsø JG, Larsen PN, Jans Ø, Kehlet H, Aasvang EK. High-dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: A double-blinded randomized clinical trial substudy. Acta Anaesthesiol Scand 2022; 66:696-703. [PMID: 35325467 PMCID: PMC9320957 DOI: 10.1111/aas.14057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Emergence delirium (ED) and postoperative delirium (POD) are associated with increased morbidity and mortality and occur in up to one-third of patients undergoing major non-cardiac surgery, where the underlying pathogenesis is multifactorial, including increased inflammation. We aimed to assess the effect of pre-operative high- versus low-dose glucocorticoid on the occurrence of ED and POD. METHODS This was a substudy from a randomized, double-blinded clinical trial. Patients ≥18 years, undergoing open liver resection were randomized 1:1 to high-dose (HD, 10 mg/kg methylprednisolone) or low-dose (LD, 8 mg dexamethasone) glucocorticoid and assessed for ED and POD for a maximum of 4 days during hospitalization. The 3-min Diagnostic Interview for CAM-defined delirium (3D-CAM) was used for assessment, 15 and 90 min after arrival in the post-anesthesia care unit (PACU), and subsequently once daily in the ward. RESULTS Fifty-three patients were included in this secondary substudy (26 HD-group and 27 LD-group). ED occurred in n = 5 HD versus n = 6 LD patients 15 min after PACU arrival. At 90 min after PACU arrival, 4 patients had ED, all from LD-group, and resulted in significantly longer PACU admission, 273 versus 178 min in ED versus Non-ED patients. During the first 4 days in the ward, n = 5 patients had at least one occurrence of POD, all from LD-group. CONCLUSIONS The primary finding of the current substudy was a lower occurrence of ED/POD in the PACU 90 min after arrival and during the first four postoperative days in patients receiving high-dose glucocorticoid compared with patients receiving low-dose glucocorticoid. The two study groups were not evenly balanced concerning known explanatory factors, i.e., age and size of surgery, which calls for larger studies to elucidate the matter.
Collapse
Affiliation(s)
- Hussein Nasser Awada
- Department of AnesthesiologyCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
- Surgical Pathophysiology UnitRigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Kristin Julia Steinthorsdottir
- Department of AnesthesiologyCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
- Surgical Pathophysiology UnitRigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Nicolai A. Schultz
- Department of Gastrointestinal Surgery and TransplantationCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Jens G. Hillingsø
- Department of Gastrointestinal Surgery and TransplantationCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Peter Nørgaard Larsen
- Department of Gastrointestinal Surgery and TransplantationCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Øivind Jans
- Department of AnesthesiologyCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Henrik Kehlet
- Surgical Pathophysiology UnitRigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Eske Kvanner Aasvang
- Department of AnesthesiologyCentre for Cancer and Organ DiseasesRigshospitalet Copenhagen University HospitalCopenhagenDenmark
- Department of Clinical MedicineFaculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| |
Collapse
|
10
|
Maniker RB, Damiano J, Ivie RMJ, Pavelic M, Woodworth GE. Perioperative Breast Analgesia: a Systematic Review of the Evidence for Perioperative Analgesic Medications. Curr Pain Headache Rep 2022; 26:299-321. [PMID: 35195851 DOI: 10.1007/s11916-022-01031-z] [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] [Accepted: 01/26/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Breast surgery is common and may result in significant acute as well as chronic pain. A wide range of pharmacologic interventions is available including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), N-methyl-D-aspartate (NMDA) receptor antagonists, anticonvulsants, and other non-opioids with analgesic properties. We present a review of the evidence for these pharmacologic interventions. A literature search of the MEDLINE database was performed via PubMed with combined terms related to breast surgery, anesthesia, and analgesia. Articles were limited to randomized controlled trial (RCT) design, adult patients undergoing elective surgery on the breast (not including biopsy), and pharmacologic interventions only. Article titles and abstracts were screened, and risk of bias assessments were performed. RECENT FINDINGS The search strategy initially captured 7254 articles of which 60 articles met the full inclusion criteria. Articles were organized according to intervention: 6 opioid agonists, 14 NSAIDs and acetaminophen, 4 alpha-2 agonists, 7 NMDA receptor antagonists, 6 local anesthetics, 7 steroids, 15 anticonvulsants (one of which also discussed an NMDA antagonist), 1 antiarrhythmic, and 2 serotonin reuptake inhibitors (one of which also studied an anticonvulsant). A wide variety of medications is effective for perioperative breast analgesia, but results vary by agent and dose. The most efficacious are likely NSAIDs and anticonvulsants. Some agents may also decrease the incidence of chronic postoperative pain, including flurbiprofen, gabapentin, venlafaxine, and memantine. While many individual agents are well studied, optimal combinations of analgesic medications remain unclear.
Collapse
Affiliation(s)
- Robert B Maniker
- Department of Anesthesiology, Columbia University, 622 West 168th Street, PH505, NY, 10032, New York, USA.
| | | | - Ryan M J Ivie
- Oregon Health and Science University, Portland, OR, USA
| | | | | |
Collapse
|
11
|
Umari M, Paluzzano G, Stella M, Carpanese V, Gallas G, Peratoner C, Colussi G, Baldo GM, Moro E, Lucangelo U, Berlot G. Dexamethasone and postoperative analgesia in minimally invasive thoracic surgery: a retrospective cohort study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2021; 1:23. [PMID: 37386655 DOI: 10.1186/s44158-021-00023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/21/2021] [Indexed: 07/01/2023]
Abstract
BACKGROUND Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting (PONV), and recent reviews suggest a role for dexamethasone in postoperative analgesia. The aim of this study is to evaluate the efficacy of dexamethasone as an analgesic adjuvant in minimally invasive thoracic surgery. Primary outcome was morphine consumption 24 h after surgery; secondary outcomes were pain control, measured as numeric rating scale (NRS), glycemic changes, PONV, and surgical wound infection. RESULTS We performed a retrospective cohort study considering 70 patients who underwent elective lobectomy, segmentectomy, or wedge resection surgery with a mini-thoracotomy approach or video-assisted thoracoscopic surgery (VATS). All patients received the same locoregional techniques and short-acting opioids during surgery; 46 patients received dexamethasone at induction. There were no significant differences in morphine consumption at 24 h (p = 0.09) and in postoperative pain scores. Nevertheless, a higher frequency of rescue therapy (p = 0.01) and a tendency for a higher attempted-PCA pushes count were observed in patients who did not receive dexamethasone. No cases of surgical wound infections were detected, and the incidence of PONV was similar in the two groups. Postoperative glycemia was transiently higher in the dexamethasone group (p = 0.004), but the need of hypoglycemic therapy was not significantly different. CONCLUSIONS Preoperative administration of dexamethasone did not cause a significant reduction in morphine consumption, but appears to be safe and plays a role in a multimodal anesthesia approach for patients undergoing elective minimally invasive thoracic surgery.
Collapse
Affiliation(s)
- Marzia Umari
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy.
| | - Giacomo Paluzzano
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy
| | - Matteo Stella
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy
| | - Valentina Carpanese
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy
| | - Giovanna Gallas
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy
| | - Caterina Peratoner
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy
| | - Giulia Colussi
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy
| | - Gaia Maria Baldo
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy
| | - Edoardo Moro
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy
| | - Umberto Lucangelo
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy
| | - Giorgio Berlot
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano-Isontina, Cattinara University Hospital, Trieste, Italy
| |
Collapse
|
12
|
Shi W, Chen Y, Zhang MQ, Che GW, Yu H. Effects of methylprednisolone on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery: A randomized controlled trial. J Clin Anesth 2021; 75:110526. [PMID: 34610541 DOI: 10.1016/j.jclinane.2021.110526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/17/2021] [Accepted: 09/23/2021] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE Evidence from previous studies indicates that glucocorticoids offer effective postoperative analgesia and improve the quality of recovery (QoR). The aim of this study was to evaluate the efficacy of preoperative methylprednisolone on early postoperative pain and QoR following thoracoscopic lung surgery. DESIGN A prospective, single-center, three-arm, double-blinded, randomized trial. SETTING Tertiary university hospital. PATIENTS Adult patients aged ≥18 years undergoing thoracoscopic lung surgery were eligible for participation. INTERVENTIONS Patients enrolled in this study were randomized to receive preoperative methylprednisolone (40 mg or 120 mg) or identical volumes of 0.9% saline. MEASUREMENTS The primary outcome was the proportion of moderate-to-severe pain (numerical rating scale [NRS] ≥ 4 when coughing during pulmonary rehabilitation exercises) on the first day postoperatively. The postoperative pain scores, QoR-15 scores and other secondary outcomes were also recorded. MAIN RESULTS Of the 180 enrolled patients, 173 patients were included in the primary analysis. The results showed that the proportion of moderate-to-severe pain was not significantly different between the combined methylprednisolone group and the placebo group (51.7% vs. 64.9%; absolute difference, 13.2%; 95% CI, -2.1% to 29.3%; P = 0.10). Patients who received methylprednisolone treatment had lower pain scores at rest and coughing on the first day after surgery than those who received placebo treatment, with mean differences of 0.5 and 0.7, respectively (P < 0.01). QoR-15 scores were higher in patients treated with methylprednisolone at day 1 (mean difference, 6.9; P < 0.001) and day 2 (mean difference, 7.2; P < 0.001) than in patients who received placebo treatment. No side-effects associated with methylprednisolone treatment were observed. CONCLUSIONS Our findings suggested that preoperative methylprednisolone (either high or low dose) has limited impact on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery, with no clinically relevant benefits detected when compared with placebo. TRIAL REGISTRATION Chinese Clinical Trail Register (identifier: ChiCTR1900021020).
Collapse
Affiliation(s)
- Wei Shi
- Department of Anesthesiology, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Ying Chen
- Department of Anesthesiology, Hospital of Integrated Traditional Chinese and Western Medicine of Liangshan Prefecture, Liangshan 615000, Sichuan, China
| | - Meng-Qiu Zhang
- Department of Anesthesiology, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Guo-Wei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Hai Yu
- Department of Anesthesiology, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China.
| |
Collapse
|
13
|
|
14
|
Steinthorsdottir KJ, Awada HN, Schultz NA, Larsen PN, Hillingsø JG, Jans Ø, Kehlet H, Aasvang EK. Preoperative high-dose glucocorticoids for early recovery after liver resection: randomized double-blinded trial. BJS Open 2021; 5:6364138. [PMID: 34480563 PMCID: PMC8418207 DOI: 10.1093/bjsopen/zrab063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/25/2021] [Accepted: 05/31/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Glucocorticoids modulate the surgical stress response. Previous studies showed that high-dose preoperative glucocorticoids reduce levels of postoperative inflammatory markers and specific biomarkers of liver damage compared with placebo, and suggested a reduced complication rate and shorter hospital stay after liver surgery. However, there are no studies with a clinical primary outcome or of early recovery outcomes. The aim of this study was to investigate whether a single high dose of preoperative glucocorticoid reduces complications in the immediate postoperative phase after liver surgery. METHODS This was a single-centre, double-blinded, parallel-group RCT investigating preoperative methylprednisolone 10 mg/kg (high dose) versus dexamethasone 8 mg (standard-dose postoperative nausea prophylaxis) in patients scheduled for open liver resection. The primary outcome was number of patients with a complication in the postanaesthesia care unit; secondary outcomes included duration of hospital stay, pain and nausea during admission, and 30-day morbidity. RESULTS A total of 174 patients (88 in high-dose group, 86 in standard-dose group) were randomized and analysed (mean(s.d.) age 65(12) years, 67.2 per cent men); 31.6 per cent had no serious co-morbidities and 25.3 per cent underwent major liver resection. Complications occurred in the postanaesthesia care unit in 51 patients (58 per cent) in the high-dose group and 58 (67 per cent) in the standard-dose group (risk ratio 0.86, 95 per cent c.i. 0.68 to 1.08; P = 0.213). Median duration of hospital stay was 4 days in both groups (P = 0.160). Thirty-day morbidity and mortality rates were similar in the two groups. CONCLUSION A high dose of preoperative glucocorticoids did not reduce acute postoperative complications after open liver resection compared with a standard dose. Registration number: NCT03403517 (http://www.clinicaltrials.gov); EudraCT 2017-002652-81 (https://eudract.ema.europa.eu/).
Collapse
Affiliation(s)
- K J Steinthorsdottir
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark.,Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - H N Awada
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - N A Schultz
- Department of Gastrointestinal Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - P N Larsen
- Department of Gastrointestinal Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - J G Hillingsø
- Department of Gastrointestinal Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Ø Jans
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - H Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - E K Aasvang
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
15
|
Early postoperative recovery after peri-acetabular osteotomy: A double-blind, randomised single-centre trial of 48 vs. 8 mg dexamethasone. Eur J Anaesthesiol 2021; 38:S41-S49. [PMID: 33399374 DOI: 10.1097/eja.0000000000001410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Peri-acetabular osteotomy is the joint-preserving treatment of choice in young adults with hip dysplasia but is associated with intense pain and high opioid consumption postoperatively. OBJECTIVES To investigate whether 48 mg of pre-operative dexamethasone was superior to a standard dose of 8 mg on reducing pain in the immediate postoperative phase. DESIGN A randomised, double-blind trial. SETTING Single-centre, primary facility. May 2017 to August 2019. PATIENTS At least 18 years undergoing peri-acetabular osteotomy. INTERVENTIONS Patients were randomised 1 : 1 to 48 or 8 mg dexamethasone intravenous (i.v.) as a single pre-operative injection. All patients received a standardised peri-operative protocol, including pre-operative acetaminophen and gabapentin, total i.v. anaesthesia and local anaesthetic catheter based wound administration. MAIN OUTCOME MEASURE Number of patients with moderate/severe pain [>3 on a numeric rating scale (NRS)] in the immediate postoperative phase. RESULTS Sixty-four patients (32 in each group) were included, and their data analysed. At some point from tracheal extubation until transfer to the ward, the NRS was more than 3 in 75% (24/32) of the 48 mg group and in 66% (21/32) in the 8 mg group, odds ratio 1.571 (95% CI, 0.552 to 4.64), P = 0.585. Patients in the 48 mg group received less opioid [cumulative rescue analgesics, oral morphine equivalents (OMEQ)] during postoperative days 0-4: median [IQR] OMEQ was 36 [15 to 85] mg vs. 79 [36 to 154] mg in the 48 and 8 mg group, respectively, P = 0.034. There were no statistically significant differences regarding complications, rate of infections or readmissions. CONCLUSION Forty-eight milligram of dexamethasone did not reduce pain in the immediate postoperative phase compared with an 8 mg dose. We observed insignificantly lower pain scores and significantly lower cumulated opioid requirements in the 48 mg group during the first four postoperative days. TRIAL REGISTRATION Clinicaltrials.gov, NCT03161938, EudraCT (2017-000544-1).
Collapse
|
16
|
Jiménez-Tornero J, Cortés-Flores AO, Chávez-Tostado M, Morgan-Villela G, Zuloaga-Fernández Del Valle C, Zuloaga-Fernández Del Valle R, García-González LA, Fernández-Avalos VS, Miranda-Ackerman RC, Alvarez-Villaseñor AS, Ambriz-González G, Barbosa-Camacho FJ, Fuentes-Orozco C, Contreras-Cordero VS, González-Ojeda A. Effect of a preoperative single-dose steroid on pulmonary function and postoperative symptoms after modified radical mastectomy: results of a randomized clinical trial. Gland Surg 2020; 9:1313-1327. [PMID: 33224806 DOI: 10.21037/gs-20-366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Evidence suggests that a preoperative single-dose steroid improves lung function and decreases the incidence of postoperative symptoms; however, this has not been sufficiently proved in modified radical mastectomy for cancer. This study aimed to evaluate the efficacy of preoperative single-dose steroid administration for postoperative lung function and postoperative symptoms in women undergoing modified radical mastectomy for breast cancer. Methods In this controlled clinical trial, conducted between June 2014 and October 2018, we examined 81 patients. Patients received a preoperative single dose of 8 mg dexamethasone (n=41; treatment group) or placebo (sterile injectable water; n=40; control group). We obtained data on postoperative nausea and vomiting and pain intensity and performed spirometry 1 h before and 1, 6, 12, and 24 h after surgery. The use of additional analgesic or antiemetic drugs was recorded. We followed up patients 30 days after discharge and recorded any surgical or medical complications. Results The age distribution and anthropometric variables of the two groups were similar. Almost 50% of the patients in each group also underwent breast reconstruction. In the treatment group, pain intensity was always lower, the incidence of postoperative nausea and vomiting was lower at 6, 12, and 24 h, and additional analgesics or antiemetics were required less frequently (P<0.05 for all). Both treatment and control groups demonstrated a restrictive ventilatory pattern immediately after surgery, which in the treatment group was reversed after 24 h. However, the reconstructed patients had a more intense and prolonged restrictive pattern (P<0.05). Surgical morbidity included one seroma observed in the control group. No infections occurred at the surgical site or at any other level, and no patient developed any metabolic disorder. No mortality was observed in either group. Conclusions This study establishes that a single preoperative dose of dexamethasone markedly decreased the incidence of postoperative nausea and vomiting and pain, improved respiratory parameters, and decreased the need for additional postoperative analgesic or antiemetic drugs. Clinical Trial Registration ClinicalTrials.gov (ID NCT02305173).
Collapse
Affiliation(s)
| | - Ana Olivia Cortés-Flores
- San Javier Hospital, Guadalajara, Jalisco, Mexico.,ANKER Global Oncology, Guadalajara, Jalisco, Mexico
| | - Mariana Chávez-Tostado
- Department of Human Reproduction, Health Sciences University Center, Universidad de Guadalajara, Jalisco, México
| | | | | | | | | | | | | | | | - Gabriela Ambriz-González
- Surgical Division, Pediatric Hospital, Western National Medical Center, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Francisco José Barbosa-Camacho
- Biomedical Research Unit 02, Specialties Hospital of the Western National Medical Center, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Clotilde Fuentes-Orozco
- Biomedical Research Unit 02, Specialties Hospital of the Western National Medical Center, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Vianca Seleste Contreras-Cordero
- Biomedical Research Unit 02, Specialties Hospital of the Western National Medical Center, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Alejandro González-Ojeda
- Biomedical Research Unit 02, Specialties Hospital of the Western National Medical Center, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| |
Collapse
|