Single-Shot Regional Anesthesia for Bariatric Surgery: a Systematic Review and Network Meta-Analysis

PURPOSE

Laparoscopic bariatric surgeries can cause intense postoperative pain. Opioid medication can alleviate the pain but can have harmful side effects especially in patients with obstructive sleep apnea. To promote early recovery, enhanced recovery after surgery guideline advises minimizing opioid use and opting for alternative analgesics. This paper aims to investigate the effect of regional anesthesia techniques through a systematic review and network meta-analysis. Primary outcome is postoperative morphine equivalent consumption at 24 h.

METHODS

Search was conducted in the following databases: PubMed, CENTRAL, Scopus, and EMBASE, from the inception until 10 January 2023. The eligibility criteria were determined by PICOS, including postoperative opioid consumption, pain scores, time to ambulate, use of additional analgesics, and adverse events. The quality assessment was performed using the Risk of Bias 2 Tool, and the certainty of evidence was assessed using the GRADE approach. Funnel plots were used to evaluate publication bias.

RESULTS

We included 22 studies in quantitative synthesis. A review of 12 studies found that all techniques had a lower mean consumption of opioids compared to placebo or no intervention, with TAP block having the greatest reduction. The quality of evidence for postoperative pain, PONV, time to deambulate, and use of rescue analgesics, was rated as moderate, with TAP block being the most effective intervention. There was no publication bias in any outcome.

CONCLUSIONS

TAP block is superior to other regional anesthesia techniques in reducing opioid consumption, pain, PONV, and use of rescue analgesics in bariatric surgery. However, further research is needed.

Single-shot regional anesthesia for laparoscopic cholecystectomies: a systematic review and network meta-analysis

BACKGROUND

Different regional anesthesia (RA) techniques have been used for laparoscopic cholecystectomy (LC), but there is no consensus on their comparative effectiveness. Our objective was to evaluate the effect of RA techniques on patients undergoing LC using a network meta-analysis approach.

METHODS

We conducted a systematic review and network meta-analysis. We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Science and Social Science Citation Index) using the following PICOS criteria: (P) adult patients undergoing LC; (I) any RA single-shot technique with injection of local anesthetics; (C) placebo or no intervention; (O) postoperative opioid consumption expressed as morphine milligram equivalents (MME), rest pain at 12 h and 24 h post-operation, postoperative nausea and vomiting (PONV), length of stay; and (S) randomized controlled trials.

RESULTS

A total of 84 studies were included. With the exception of the rectus sheath block (P = 0.301), the RA techniques were superior to placebo at reducing opioid consumption. Regarding postoperative pain, the transversus abdominis plane (TAP) block (-1.80 on an 11-point pain scale) and erector spinae plane (ESP) block (-1.33 on an 11-point pain scale) were the most effective at 12 and 24 h. The TAP block was also associated with the greatest reduction in PONV.

CONCLUSIONS

RA techniques are effective at reducing intraoperative opioid use, postoperative pain, and PONV in patients undergoing LC. Patients benefit the most from the bilateral paravertebral, ESP, quadratus lumborum, and TAP blocks.

Cervical cancer screening programs in low-income communities. Experiences from Ecuador. Low cost detection of HPV infection in a developing country

OBJECTIVES

With the support of the independent humanitarian organization "Amici Fundation Terra Nueva" in Quito, Ecuador, we evaluated the feasibility of a cytologic screening program sustained by volunteers on the field and in Italy.

METHODS

250 women underwent a cervical Pap-test. The women with a positive Pap-smear were re-called for visual inspection with acetic acid (VIA), whereas those with a negative smear were invited for a new Pap-test after 3 years. To obtain samples for molecular assays, cytologic material was removed from slides, submitted to DNA extraction and amplified by nested PCR of the L1 region of HPV DNA. PCR-positive samples were sequenced. RESULTS. Six (2.6%) samples showed squamous intra-epithelial lesions (SILs): 4 low grade and 2 high grade SILs were present in women more than 40 years old. The overall rate of successful DNA recovery on a per-slide basis was 96.5%. High grade SILs were characterized by HPV 16 and 18 co-infection. HPV 16 was detected in one low grade SIL. HPV-DNA was detected in 11 smears (4.95%): in all 6 SILS and in 5 of the 216 negative smears.

CONCLUSION

Independent humanitarian organizations could play a role in supporting national screening programs offering skilled field professionals and technical support by scientists operating in their countries. Our molecular technique has the potential to provide important epidemiological information in many resource-poor areas of developing countries.

[A comparison of ventilation techniques in ARDS. Volume controlled vs pressure regulated volume control]

OBJECTIVE

Comparison between effects of a new method of mechanical ventilation (PRVC) and Volume Controlled ventilation in the ARDS treatment.

DESIGN

Prospective study from March 1995 to March 1997.

PLACE

Intensive Care Unit of Sanremo Hospital.

PATIENTS

Nine patients, six males and three females, average age 49.2 years, average SAPS 35.5, with moderate to severe ARDS related to various etiologies.

INTERVENTIONS

Patient were first ventilated with Siemens Servo Ventilators 300 in Volume controlled. They were then ventilated with Pressure-regulated Volume Control maintaining the same ventilation parameters (TV, RR, FiO2, PEEP and I:E ratio).

MEASUREMENTS

After a 60 minute stabilisation period in each method, Peak inspiratory pressure, Static Compliance, PaO2, PaCO2, AaDO2 and cardiovascular parameters were measured.

RESULTS

With the PRVC ventilation an important decrease of PIP and an improvement of PaO2 and SaO2 were observed.

CONCLUSIONS

Although it is not possible to draw any conclusion on morbidity and mortality in patients treated with PRVC versus VC, for gas exchange and compliance improvement and for inspiratory pressure decrease with consequent reduction of barotrauma, it may be affirm that PCRV seems to be the best ventilation methods in the ARDS treatment.

Renovascular hypertension with low-to-normal plasma renin: clinical and angiographic features

1. Low-to-normal renin renovascular hypertension (RVH) and the accuracy of renal vein renin ratios were investigated in 129 consecutive patients referred for suspected RVH. Forty-nine had essential hypertension, 24 unilateral renoparenchymal hypertension and 56 renal artery obstruction. Of the latter, 86% were diagnosed retrospectively as RVH, based on fall in blood pressure with correction of renal ischaemia. We measured baseline, captopril-stimulated and renal vein plasma renin activity (PRA) levels, as well as several other parameters. 2. PRA was low-to-normal in 37% of the RVH patients [low-to-normal renin (LNR-) RVH group] and elevated in the remaining 63% [high-renin (HR-) RVH group]. In the LNR-RVH group, low-to-normal renin levels, by immunoreactive active renin and plasma renin concentration measurements, and a blunted response of PRA to captopril, were seen. As compared with HR-RVH, LNR-RVH patients had a longer duration of hypertension (P < 0.05), higher serum K+ (P = 0.04) and lower diastolic blood pressure (P = 0.02). However, they did not differ for the other variables, including the fall in blood pressure after correction of renal ischaemia. Although the number of bilateral stenoses was similar in the two groups, no patient in the LNR-RVH group had total renal artery occlusion compared with 53% in the HR-RVH group (P = 0.00015). The accuracy of renal vein renin indices were high enough to justify their use only in the patients with total occlusion of a renal artery. 3. Thus LNR-RVH is common in patients with longstanding hypertension without a totally occluded renal artery. Since the sensitivity of renin measurements is low, cure of hypertension would be precluded for more than one third of RVH patients, if these tests were a prerequisite for identifying RVH.

Efficacy of recombinant alpha-interferon 2a and 13-cis-retinoic acid in the treatment of squamous cell carcinoma

BACKGROUND

Recent in vitro and in vivo studies hypothesize a synergistic effect of 13-cis-Retinoic Acid (13cRA) and recombinant alpha-IFN 2a (alpha-IFN) in the treatment of squamous cell carcinoma (SqCC).

PATIENTS AND METHODS

35 patients with SqCC in several sites were treated with 13cRA (0.6-1 mg/kg/day) combined with alpha-IFN (6 x 10(6) I.U./day), continuously for 3 months.

RESULTS

We observed an objective response in 41% of cases (13/32 evaluable patients) with 5 complete and 8 partial responses. Toxicity was mild and always rapidly reversible, with no haematological side effects.

CONCLUSIONS

These preliminary data confirm the feasibility and effectiveness of the combination of 13cRA and alpha-IFN in the therapy of SqCC, also in pre-treated patients, with acceptable toxicity and good compliance.

Apheresis for severe malaria complicated by cerebral malaria, acute respiratory distress syndrome, acute renal failure, and disseminated intravascular coagulation

Malaria has become a very uncommon disease in Italy. Recently a variety of circumstances, such as travel to tropical countries as well as immigration from Asia and Africa, have combined to increase the number of malaria cases recorded annually. In this report we describe the use of red cell exchange transfusion and plasma exchange in the treatment of a patient with hyperparasitemic malaria (51% erythrocytes or more parasitized). When first observed the patient was in shock and had signs of cerebral malaria, disseminated intravascular coagulation, and acute respiratory distress syndrome, which in the following 2 days were complicated by acute renal failure. After mefloquine therapy combined with 3 red blood cell exchanges, 2 plasma exchanges, and 10 dialysis sessions over 14 days, the patient recovered completely. This case of severe malaria with multiple complications, treated with mefloquine in conjunction with both exchange transfusion and plasmapheresis, had a successful outcome and lends further support to the possible beneficial role of exchange transfusion in complicated malaria.

[Blood pressure monitoring during hospital convalescence]

Blood pressure ambulatory monitoring has provided numerous and interesting informations on the clinical as well as investigational setting of arterial hypertension. The vast majority of data have been obtained registering blood pressure during the normal daily activities of the patients and surprisingly few studies have been undertaken to evaluate blood pressure behaviour in inpatients. We observed the 24 hours pattern of blood pressure in hypertensive and normotensive inpatients, using an automated sphygmomanometer (Omega 1400), whose performance was previously evaluated by us. The results demonstrate that blood pressure monitoring in inpatients could be a useful tool in managing hypertensive patients.

[Evaluation of the characteristics and performance of an automatic sphygmomanometer (Omega 1400)]

24 hour pressure monitoring is a newly developing technique potentially yielding important informations in hypertensive patients. Numerous automated devices are available whose performance characteristics are poorly documented. To evaluate an automated sphygmomanometer commonly used in our Division (Omega 1400, Invivo Research Laboratories), we performed a series of measurements, simultaneously recording blood pressure in the opposite arm with a common sphygmomanometer. Each measure was then repeated reversing the position of the two devices (manual and automated), thus abolishing possible differences between the two arms. We observed a mean underestimation of 1.90 mmHg of systolic pressure and of 4.82 mmHg of diastolic blood pressure by the automated device. We conclude that the device by us evaluated is not advisable in the basal blood pressure evaluation, but useful in monitoring inpatients.

[Screening with latex IgM reagent on umbilical cord blood for demonstration of intrauterine infections]

The AA. have found IgM in cord sera of 903 newborns. In 13 (1.44%) there was an increase of IgM and the control made on neonatal serum within the first 5 days from birth has shown a positive result only in 1 case (7.69% of positives). The AA. present, in the conclusions, some considerations that justify the results of their work.