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Jacobs LM, Helder LS, Albers KI, Kranendonk J, Keijzer C, Joosten LA, Strobbe LJ, Warlé MC. The role of surgical tissue injury and intraoperative sympathetic activation in postoperative immunosuppression after breast-conserving surgery versus mastectomy: a prospective observational study. Breast Cancer Res 2024; 26:42. [PMID: 38468349 PMCID: PMC10926636 DOI: 10.1186/s13058-024-01801-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/28/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Breast cancer is the second most common cause of death from cancer in women worldwide. Counterintuitively, large population-based retrospective trials report better survival after breast-conserving surgery (BCS) compared to mastectomy, corrected for tumour- and patient variables. More extensive surgical tissue injury and activation of the sympathetic nervous system by nociceptive stimuli are associated with immune suppression. We hypothesized that mastectomy causes a higher expression of plasma damage associated molecular patterns (DAMPs) and more intraoperative sympathetic activation which induce postoperative immune dysregulation. Immune suppression can lead to postoperative complications and affect tumour-free survival. METHODS In this prospective observational study, plasma DAMPs (HMGB1, HSP70, S100A8/A9 and S100A12), intraoperative sympathetic activation (Nociception Level (NOL) index from 0 to 100), and postoperative immune function (plasma cytokine concentrations and ex vivo cytokine production capacity) were compared in patients undergoing elective BCS (n = 20) versus mastectomy (n = 20). RESULTS Ex vivo cytokine production capacity of TNF, IL-6 and IL-1β was nearly absent in both groups one hour after surgery. Levels appeared recovered on postoperative day 3 (POD3), with significantly higher ex vivo production capacity of IL-1β after BCS (p = .041) compared to mastectomy. Plasma concentration of IL-6 was higher one hour after mastectomy (p = .045). Concentrations of plasma alarmins S100A8/A9 and S100A12 were significantly higher on POD3 after mastectomy (p = .003 and p = .041, respectively). Regression analysis showed a significantly lower percentage of NOL measurements ≤ 8 (absence of nociception) during mastectomy when corrected for norepinephrine equivalents (36% versus 45% respectively, p = .038). Percentage of NOL measurements ≤ 8 of all patients correlated with ex vivo cytokine production capacity of IL-1β and TNF on POD3 (r = .408; p = .011 and r = .500; p = .001, respectively). CONCLUSIONS This pilot study revealed substantial early postoperative immune suppression after BCS and mastectomy that appears to recover in the following days. Differences between BCS and mastectomy in release of DAMPs and intraoperative sympathetic activation could affect postoperative immune homeostasis and thereby contribute to the better survival reported after BCS in previous large population-based retrospective trials. These results endorse further exploration of (1) S100 alarmins as potential therapeutic targets in breast cancer surgery and (2) suppression of intraoperative sympathetic activation to substantiate the observed association with postoperative immune dysregulation.
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Affiliation(s)
- Lotte Mc Jacobs
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Leonie S Helder
- Department of Anaesthesiology, Radboudumc, Nijmegen, The Netherlands
| | - Kim I Albers
- Department of Anaesthesiology, Radboudumc, Nijmegen, The Netherlands
| | - Josephine Kranendonk
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein zuid 10, Nijmegen, 6525 GA, The Netherlands
| | | | - Leo Ab Joosten
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
- Department of Medical Genetics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj- Napoca, Romania
| | - Luc Ja Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein zuid 10, Nijmegen, 6525 GA, The Netherlands.
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Bijkerk V, Jacobs LM, Albers KI, Gurusamy KS, van Laarhoven CJ, Keijzer C, Warlé MC. Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure. Cochrane Database Syst Rev 2024; 1:CD013197. [PMID: 38288876 PMCID: PMC10825891 DOI: 10.1002/14651858.cd013197.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Laparoscopic surgery is the preferred option for many procedures. To properly perform laparoscopic surgery, it is essential that sudden movements and abdominal contractions in patients are prevented, as it limits the surgeon's view. There has been a growing interest in the potential beneficial effect of deep neuromuscular blockade (NMB) in laparoscopic surgery. Deep NMB improves the surgical field by preventing abdominal contractions, and it is thought to decrease postoperative pain. However, it is uncertain if deep NMB improves intraoperative safety and thereby improves clinical outcomes. OBJECTIVES To evaluate the benefits and harms of deep neuromuscular blockade versus no, shallow, or moderate neuromuscular blockade during laparoscopic intra- or transperitoneal procedures in adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 31 July 2023. SELECTION CRITERIA We included randomised clinical trials (irrespective of language, blinding, or publication status) in adults undergoing laparoscopic intra- or transperitoneal procedures comparing deep NMB to moderate, shallow, or no NMB. We excluded trials that did not report any of the primary or secondary outcomes of our review. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. health-related quality of life, and 3. proportion of participants with serious adverse events. Our secondary outcomes were 4. proportion of participants with non-serious adverse events, 5. readmissions within three months, 6. short-term pain scores, 7. measurements of postoperative recovery, and 8. operating time. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 42 randomised clinical trials with 3898 participants. Most trials included participants undergoing intraperitoneal oncological resection surgery. We present the Peto fixed-effect model for most dichotomous outcomes as only sparse events were reported. Comparison 1: deep versus moderate NMB Thirty-eight trials compared deep versus moderate NMB. Deep NMB may have no effect on mortality, but the evidence is very uncertain (Peto odds ratio (OR) 7.22, 95% confidence interval (CI) 0.45 to 115.43; 12 trials, 1390 participants; very low-certainty evidence). Deep NMB likely results in little to no difference in health-related quality of life up to four days postoperative (mean difference (MD) 4.53 favouring deep NMB on the Quality of Recovery-40 score, 95% CI 0.96 to 8.09; 5 trials, 440 participants; moderate-certainty evidence; mean difference lower than the mean clinically important difference of 10 points). The evidence is very uncertain about the effect of deep NMB on intraoperatively serious adverse events (deep NMB 38/1150 versus moderate NMB 38/1076; Peto OR 0.95, 95% CI 0.59 to 1.52; 21 trials, 2231 participants; very low-certainty evidence), short-term serious adverse events (up to 60 days) (deep NMB 37/912 versus moderate NMB 42/852; Peto OR 0.90, 95% CI 0.56 to 1.42; 16 trials, 1764 participants; very low-certainty evidence), and short-term non-serious adverse events (Peto OR 0.94, 95% CI 0.65 to 1.35; 11 trials, 1232 participants; very low-certainty evidence). Deep NMB likely does not alter the duration of surgery (MD -0.51 minutes, 95% CI -3.35 to 2.32; 34 trials, 3143 participants; moderate-certainty evidence). The evidence is uncertain if deep NMB alters the length of hospital stay (MD -0.22 days, 95% CI -0.49 to 0.06; 19 trials, 2084 participants; low-certainty evidence) or pain scores one hour after surgery (MD -0.31 points on the numeric rating scale, 95% CI -0.59 to -0.03; 22 trials, 1823 participants; very low-certainty evidence; mean clinically important difference 1 point) and 24 hours after surgery (MD -0.60 points on the numeric rating scale, 95% CI -1.05 to -0.15; 16 trials, 1404 participants; very low-certainty evidence; mean clinically important difference 1 point). Comparison 2: deep versus shallow NMB Three trials compared deep versus shallow NMB. The trials did not report on mortality and health-related quality of life. The evidence is very uncertain about the effect of deep NMB compared to shallow NMB on the proportion of serious adverse events (RR 1.66, 95% CI 0.50 to 5.57; 2 trials, 158 participants; very low-certainty evidence). Comparison 3: deep versus no NMB One trial compared deep versus no NMB. There was no mortality in this trial, and health-related quality of life was not reported. The proportion of serious adverse events was 0/25 in the deep NMB group and 1/25 in the no NMB group. AUTHORS' CONCLUSIONS There was insufficient evidence to draw conclusions about the effects of deep NMB compared to moderate NMB on all-cause mortality and serious adverse events. Deep NMB likely results in little to no difference in health-related quality of life and duration of surgery compared to moderate NMB, and it may have no effect on the length of hospital stay. Due to the very low-certainty evidence, we do not know what the effect is of deep NMB on non-serious adverse events, pain scores, or readmission rates. Randomised clinical trials with adequate reporting of all adverse events would reduce the current uncertainties. Due to the low number of identified trials and the very low certainty of evidence, we do not know what the effect of deep NMB on serious adverse events is compared to shallow NMB and no NMB. We found no trials evaluating mortality and health-related quality of life.
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Affiliation(s)
- Veerle Bijkerk
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Mc Jacobs
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kim I Albers
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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3
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Reijnders-Boerboom GT, Albers KI, Jacobs LM, van Helden E, Rosman C, Díaz-Cambronero O, Mazzinari G, Scheffer GJ, Keijzer C, Warlé MC. Low intra-abdominal pressure in laparoscopic surgery: a systematic review and meta-analysis. Int J Surg 2023; 109:1400-1411. [PMID: 37026807 PMCID: PMC10389627 DOI: 10.1097/js9.0000000000000289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 02/03/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Guidelines do not provide clear recommendations with regard to the use of low intra-abdominal pressure (IAP) during laparoscopic surgery. The aim of this meta-analysis is to assess the influence of low versus standard IAP during laparoscopic surgery on the key-outcomes in perioperative medicine as defined by the StEP-COMPAC consensus group. MATERIALS AND METHODS We searched the Cochrane Library, PubMed, and EMBASE for randomized controlled trials comparing low IAP (<10 mmHg) with standard IAP (10 mmHg or higher) during laparoscopic surgery without time, language, or blinding restrictions. According to the PRISMA guidelines, two review authors independently identified trials and extracted data. Risk ratio (RR), and mean difference (MD), with 95% CIs were calculated using random-effects models with RevMan5. Main outcomes were based on StEP-COMPAC recommendations, and included postoperative complications, postoperative pain, postoperative nausea and vomiting (PONV) scores, and length of hospital stay. RESULTS Eighty-five studies in a wide range of laparoscopic procedures (7349 patients) were included in this meta-analysis. The available evidence indicates that the use of low IAP (<10 mmHg) leads to a lower incidence of mild (Clavien-Dindo grade 1-2) postoperative complications (RR=0.68, 95% CI: 0.53-0.86), lower pain scores (MD=-0.68, 95% CI: -0.82 to 0.54) and PONV incidence (RR=0.67, 95% CI: 0.51-0.88), and a reduced length of hospital stay (MD=-0.29, 95% CI: -0.46 to 0.11). Low IAP did not increase the risk of intraoperative complications (RR=1.15, 95% CI: 0.77-1.73). CONCLUSIONS Given the established safety and the reduced incidence of mild postoperative complications, lower pain scores, reduced incidence of PONV, and shorter length of stay, the available evidence supports a moderate to strong recommendation (1a level of evidence) in favor of low IAP during laparoscopic surgery.
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Affiliation(s)
| | - Kim I. Albers
- Departments of Anesthesiology
- Surgery, Radboudumc, Nijmegen, The Netherlands
| | | | | | | | - Oscar Díaz-Cambronero
- Department of Anesthesiology, La Fé University and Polytechnic Hospital, Valencia, Spain
| | - Guido Mazzinari
- Department of Anesthesiology, La Fé University and Polytechnic Hospital, Valencia, Spain
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de Graaff MR, Hogenbirk RNM, Janssen YF, Elfrink AKE, Liem RSL, Nienhuijs SW, de Vries JPPM, Elshof JW, Verdaasdonk E, Melenhorst J, van Westreenen HL, Besselink MGH, Ruurda JP, van Berge Henegouwen MI, Klaase JM, den Dulk M, van Heijl M, Hegeman JH, Braun J, Voeten DM, Würdemann FS, Warps ALK, Alberga AJ, Suurmeijer JA, Akpinar EO, Wolfhagen N, van den Boom AL, Bolster-van Eenennaam MJ, van Duijvendijk P, Heineman DJ, Wouters MWJM, Kruijff S, Koningswoud-Terhoeve CL, Belt E, van der Hoeven JAB, Marres GMH, Tozzi F, von Meyenfeldt EM, Coebergh RRJ, van den Braak, Huisman S, Rijken AM, Balm R, Daams F, Dickhoff C, Eshuis WJ, Gisbertz SS, Zandbergen HR, Hartemink KJ, Keessen SA, Kok NFM, Kuhlmann KFD, van Sandick JW, Veenhof AA, Wals A, van Diepen MS, Schoonderwoerd L, Stevens CT, Susa D, Bendermacher BLW, Olofsen N, van Himbeeck M, de Hingh IHJT, Janssen HJB, Luyer MDP, Nieuwenhuijzen GAP, Ramaekers M, Stacie R, Talsma AK, Tissink MW, Dolmans D, Berendsen R, Heisterkamp J, Jansen WA, de Kort-van Oudheusden M, Matthijsen RM, Grünhagen DJ, Lagarde SM, Maat APWM, van der Sluis PC, Waalboer RB, Brehm V, van Brussel JP, Morak M, Ponfoort ED, Sybrandy JEM, Klemm PL, Lastdrager W, Palamba HW, van Aalten SM, Tseng LNL, van der Bogt KEA, de Jong WJ, Oosterhuis JWA, Tummers Q, van der Wilden GM, Ooms S, Pasveer EH, Veger HTC, Molegraafb MJ, Nieuwenhuijs VB, Patijn GA, van der Veldt MEV, Boersma D, van Haelst STW, van Koeverden ID, Rots ML, Bonsing BA, Michiels N, Bijlstra OD, Braun J, Broekhuis D, Brummelaar HW, Hartgrink HH, Metselaar A, Mieog JSD, Schipper IB, de Steur WO, Fioole B, Terlouw EC, Biesmans C, Bosmans JWAM, Bouwense SAW, Clermonts SHEM, Coolsen MME, Mees BME, Schurink GWH, Duijff JW, van Gent T, de Nes LCF, Toonen D, Beverwijk MJ, van den Hoed E, Keizers B, Kelder W, Keller BPJA, Pultrum BB, van Rosum E, Wijma AG, van den Broek F, Leclercq WKG, Loos MJA, Sijmons JML, Vaes RHD, Vancoillie PJ, Consten ECJ, Jongen JMJ, Verheijen PM, van Weel V, Arts CHP, Jonker J, Murrmann-Boonstra G, Pierie JPEN, Swart J, van Duyn EB, Geelkerken RH, de Groot R, Moekotte NL, Stam A, Voshaar A, van Acker GJD, Bulder RMA, Swank DJ, Pereboom ITA, Hoffmann WH, Orsini M, Blok JJ, Lardenoije JHP, Reijne MMPJ, van Schaik P, Smeets L, van Sterkenburg SMM, Harlaar NJ, Mekke S, Verhaakt T, Cancrinus E, van Lammeren GW, Molenaar IQ, van Santvoort HC, Vos AWF, Schouten- van der Velden AP, Woensdregt K, Mooy-Vermaat SP, Scharn DM, Marsman HA, Rassam F, Halfwerk FR, Andela AJ, Buis CI, van Dam GM, ten Duis K, van Etten B, Lases L, Meerdink M, de Meijer VE, Pranger B, Ruiter S, Rurenga M, Wiersma A, Wijsmuller AR, Albers KI, van den Boezem PB, Klarenbeek B, van der Kolk BM, van Laarhoven CJHM, Matthée E, Peters N, Rosman C, Schroen AMA, Stommel MWJ, Verhagen AFTM, van der Vijver R, Warlé MC, de Wilt JHW, van den Berg JW, Bloemert T, de Borst GJ, van Hattum EH, Hazenberg CEVB, van Herwaarden JA, van Hillegerberg R, Kroese TE, Petri BJ, Toorop RJ, Aarts F, Janssen RJL, Janssen-Maessen SHP, Kool M, Verberght H, Moes DE, Smit JW, Wiersema AM, Vierhout BP, de Vos B, den Boer FC, Dekker NAM, Botman JMJ, van Det MJ, Folbert EC, de Jong E, Koenen JC, Kouwenhoven EA, Masselink I, Navis LH, Belgers HJ, Sosef MN, Stoot JHMB. Impact of the COVID-19 pandemic on surgical care in the Netherlands. Br J Surg 2022; 109:1282-1292. [PMID: 36811624 PMCID: PMC10364688 DOI: 10.1093/bjs/znac301] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/14/2022] [Accepted: 07/31/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands. METHODS A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018-2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates. RESULTS Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018-2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001). CONCLUSION The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.
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Affiliation(s)
- Michelle R de Graaff
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands.,Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, Gelre Ziekenhuizen, Apeldoorn, the Netherlands
| | - Rianne N M Hogenbirk
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Yester F Janssen
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Arthur K E Elfrink
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ronald S L Liem
- Department of Surgery, Dutch Obesity Clinic, Gouda, the Netherlands.,Department of Surgery, Groene Hart Hospital, Gouda, the Netherlands
| | - Simon W Nienhuijs
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan-Willem Elshof
- Department of Surgery, VieCuri Medical Centre, Venlo, the Netherlands
| | - Emiel Verdaasdonk
- Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Marc G H Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands.,Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Joost M Klaase
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mark van Heijl
- Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - Johannes H Hegeman
- Department of Surgery, Ziekenhuisgroep Twente Almelo-Hengelo, Almelo, Hengelo, the Netherlands
| | - Jerry Braun
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Daan M Voeten
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Franka S Würdemann
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Anne-Loes K Warps
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Anna J Alberga
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands.,Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Erman O Akpinar
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Nienke Wolfhagen
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | | | | | - David J Heineman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
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van Helden EV, van Uitert A, Albers KI, Steegers MAH, Timmers HJLM, d'Ancona FCH, van der Wal SEI, Scheffer GJ, Keijzer C, Warlé MC, Langenhuijsen JF. Chronic postsurgical pain after minimally invasive adrenalectomy: prevalence and impact on quality of life. BMC Anesthesiol 2022; 22:153. [PMID: 35590236 PMCID: PMC9118616 DOI: 10.1186/s12871-022-01696-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/14/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Minimally invasive adrenalectomy is the standard of care for small adrenal tumours. Both the transperitoneal lateral approach and posterior retroperitoneal approach are widely used and have been proven to be safe and effective. However, the prevalence of chronic postsurgical pain has not been specifically investigated in previous studies. The primary goal of this study was to identify the prevalence of chronic postsurgical pain after minimally invasive adrenalectomy. METHODS A cross-sectional study was performed among all consecutive patients who had undergone minimally invasive adrenalectomy in a single university medical centre. The primary outcome was the prevalence of chronic postsurgical pain. Secondary outcomes were the prevalence of localized hypoesthesia, risk factors for the development of chronic postsurgical pain, and the Health-Related Quality of Life. Three questionnaires were used to measure the prevalence and severity of chronic postsurgical pain, hypoesthesia, and Health-Related Quality of Life. Logistic regression analysis was performed to determine risk factors for development of chronic postsurgical pain. RESULTS Six hundred two patients underwent minimally invasive adrenalectomy between January 2007 and September 2019, of whom 328 signed informed consent. The prevalence of chronic postsurgical pain was 14.9%. In the group of patients with chronic postsurgical pain, 33% reported hypoesthesia as well. Young age was a significant predictor for developing chronic postsurgical pain. The prevalence of localized hypoesthesia was 15.2%. In patients with chronic postsurgical pain, Health-Related Quality of Life was significantly lower, compared to patients without pain. CONCLUSIONS The prevalence of chronic postsurgical pain following minimally invasive adrenalectomy is considerable. Furthermore, the presence of chronic postsurgical pain was correlated with a significant and clinically relevant lower Health-Related Quality of Life. These findings should be included in the preoperative counselling of the patient. In the absence of evidence for effective treatment in established chronic pain, prevention should be the key strategy and topic of future research.
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Affiliation(s)
- Esmee V van Helden
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
| | - Allon van Uitert
- Department of Urology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Kim I Albers
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Amsterdam University Medical Center, De Boelelaan 1118, 1081, HV, Amsterdam, The Netherlands
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Frank C H d'Ancona
- Department of Urology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Selina E I van der Wal
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Gert Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Johan F Langenhuijsen
- Department of Urology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
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Reijnders-Boerboom GTJA, van Helden EV, Minnee RC, Albers KI, Bruintjes MHD, Dahan A, Martini CH, d'Ancona FCH, Scheffer GJ, Keijzer C, Warlé MC. Deep neuromuscular block reduces the incidence of intra-operative complications during laparoscopic donor nephrectomy: a pooled analysis of randomized controlled trials. Perioper Med (Lond) 2021; 10:56. [PMID: 34879862 PMCID: PMC8656013 DOI: 10.1186/s13741-021-00224-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
Study objective To assess whether different intensities of intra-abdominal pressure and deep neuromuscular blockade influence the risk of intra-operative surgical complications during laparoscopic donor nephrectomy. Design A pooled analysis of ten previously performed prospective randomized controlled trials. Setting Laparoscopic donor nephrectomy performed in four academic hospitals in the Netherlands: Radboudumc, Leiden UMC, Erasmus MC Rotterdam, and Amsterdam UMC. Patients Five hundred fifty-six patients undergoing a transperitoneal, fully laparoscopic donor nephrectomy enrolled in ten prospective, randomized controlled trials conducted in the Netherlands from 2001 to 2017. Interventions Moderate (tetanic count of four > 1) versus deep (post-tetanic count 1–5) neuromuscular blockade and standard (≥10 mmHg) versus low (<10 mmHg) intra-abdominal pressure. Measurements The primary endpoint is the number of intra-operative surgical complications defined as any deviation from the ideal intra-operative course occurring between skin incision and closure with five severity grades, according to ClassIntra. Multiple logistic regression analyses were used to identify predictors of intra- and postoperative complications. Main results In 53/556 (9.5%) patients, an intra-operative complication with ClassIntra grade ≥ 2 occurred. Multiple logistic regression analyses showed standard intra-abdominal pressure (OR 0.318, 95% CI 0.118–0.862; p = 0.024) as a predictor of less intra-operative complications and moderate neuromuscular blockade (OR 3.518, 95% CI 1.244–9.948; p = 0.018) as a predictor of more intra-operative complications. Postoperative complications occurred in 31/556 (6.8%), without significant predictors in multiple logistic regression analyses. Conclusions Our data indicate that the use of deep neuromuscular blockade could increase safety during laparoscopic donor nephrectomy. Future randomized clinical trials should be performed to confirm this and to pursue whether it also applies to other types of laparoscopic surgery. Trial registration Clinicaltrials.gov LEOPARD-2 (NCT02146417), LEOPARD-3 trial (NCT02602964), and RELAX-1 study (NCT02838134), Klop et al. (NTR 3096), Dols et al. 2014 (NTR1433).
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Affiliation(s)
- Gabby T J A Reijnders-Boerboom
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands. .,Department of Anaesthesiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
| | - Esmee V van Helden
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.,Department of Anaesthesiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Robert C Minnee
- Department of Surgery, Erasmus Medical Centre, Doctor Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Kim I Albers
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.,Department of Anaesthesiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Moira H D Bruintjes
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Albert Dahan
- Department of Anaesthesiology, Leiden University Medical Centre, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Chris H Martini
- Department of Anaesthesiology, Leiden University Medical Centre, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Frank C H d'Ancona
- Department of Urology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Gert-Jan Scheffer
- Department of Anaesthesiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Christiaan Keijzer
- Department of Anaesthesiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
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7
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Albers KI, Polat F, Panhuizen IF, Snoeck MMJ, Scheffer GJ, de Boer HD, Warlé MC. The effect of low- versus normal-pressure pneumoperitoneum during laparoscopic colorectal surgery on the early quality of recovery with perioperative care according to the enhanced recovery principles (RECOVER): study protocol for a randomized controlled study. Trials 2020; 21:541. [PMID: 32552782 PMCID: PMC7301516 DOI: 10.1186/s13063-020-04496-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 06/10/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND There is increasing evidence for the use of lower insufflation pressures during laparoscopic surgery. Deep neuromuscular blockade allows for a safe reduction in intra-abdominal pressure without compromising the quality of the surgical field. While there is considerable evidence to support superior surgical conditions during deep neuromuscular blockade, there is only a limited amount of studies investigating patient outcomes. Moreover, results are not always consistent between studies and vary between different types of laparoscopic surgery. This study will investigate the effect of low-pressure pneumoperitoneum facilitated by deep NMB on quality of recovery after laparoscopic colorectal surgery. METHODS The RECOVER study is a multicenter double-blinded randomized controlled trial consisting of 204 patients who will be randomized in a 1:1 fashion to group A, low-pressure pneumoperitoneum (8 mmHg) facilitated by deep neuromuscular blockade (post tetanic count of 1-2), or group B, normal-pressure pneumoperitoneum (12 mmHg) with moderate neuromuscular blockade (train-of-four response of 1-2). The primary outcome is quality of recovery on postoperative day 1, quantified by the Quality of Recovery-40 questionnaire. DISCUSSION Few studies have investigated the effect of lower insufflation pressures facilitated by deep neuromuscular blockade on patient outcomes after laparoscopic colorectal procedures. This study will identify whether low pressure pneumoperitoneum and deep neuromuscular blockade will enhance recovery after colorectal laparoscopic surgery and, moreover, if this could be a valuable addition to the Enhanced Recovery After Surgery guidelines. TRIAL REGISTRATION EudraCT 2018-001485-42. Registered on April 9, 2018. Clinicaltrials.govNCT03608436. Registered on July 30, 2018.
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Affiliation(s)
- Kim I. Albers
- Department of Surgery and Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Fatih Polat
- Department of Surgery, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Ivo F. Panhuizen
- Department of Anesthesiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Marc M. J. Snoeck
- Department of Anesthesiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Gert-Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Hans D. de Boer
- Department of Anesthesiology, Martini General Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - Michiel C. Warlé
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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Albers KI, Polat F, Loonen T, Graat LJ, Mulier JP, Snoeck MMJ, Panhuizen IF, Vermulst AA, Scheffer GJ, Warlé MC. Visualising improved peritoneal perfusion at lower intra-abdominal pressure by fluorescent imaging during laparoscopic surgery: A randomised controlled study. Int J Surg 2020; 77:8-13. [DOI: 10.1016/j.ijsu.2020.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 02/08/2023]
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Albers KI, Diaz-Cambronero O, Keijzer C, Snoeck MMJ, Warlé MC, Fuchs-Buder T. Revisiting the Classification of Neuromuscular Blockade, Aligning Clinical Practice and Research. Anesth Analg 2019; 129:e176-e178. [PMID: 31498186 DOI: 10.1213/ane.0000000000004407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Kim I Albers
- Departments of Anaesthesiology and Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands, Department of Anaesthesiology, Hospital Universitari i Politecnic la Fe, Valencia, Spain, Perioperative Medicine Research Group, Instituto de Investigación Sanitaria la Fe, Valencia, Spain Department of Anaesthesiology, Radboud University Medical Centre, Nijmegen, the Netherlands Department of Anaesthesiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands Département d'Anesthésie et de Réanimation, Centre Hospitalier Universitaire Nancy/Brabois, Nancy, France
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10
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Bruintjes MH, Albers KI, Gurusamy KS, Rovers MM, van Laarhoven CJHM, Warle MC. Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure. Hippokratia 2018. [DOI: 10.1002/14651858.cd013197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Moira H Bruintjes
- Radboud University Nijmegen Medical Center; Department of Surgery; Geert Grooteplein Zuid 10 Nijmegen Netherlands 6525 GA
| | - Kim I Albers
- Radboud University Nijmegen Medical Centre; Department of Anesthesiology; Nijmegen Netherlands
| | - Kurinchi Selvan Gurusamy
- University College London; Division of Surgery and Interventional Science; 9th Floor, Royal Free Hospital Rowland Hill Street London UK NW3 2PF
| | - Maroeska M Rovers
- Radboud University Nijmegen Medical Centre; Department of Operating Rooms; Hp 630, route 631 PO Box 9101 Nijmegen Netherlands 6500 HB
| | - Cornelis JHM van Laarhoven
- Radboud University Nijmegen Medical Centre; Department of Surgery; PO Box 9101 internal code 618 Nijmegen Netherlands 6500 HB
| | - Michiel C Warle
- Radboud University Nijmegen Medical Center; Department of Surgery; Geert Grooteplein Zuid 10 Nijmegen Netherlands 6525 GA
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Albers KI, Martini CH, Scheffer GJ, Warlé MC. Letter to the editor: considering the effects of deep neuromuscular blockade on endoscopic surgical conditions during transurethral resection of a bladder tumor (TURB). World J Urol 2018; 36:2093-2094. [PMID: 30039389 DOI: 10.1007/s00345-018-2417-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 11/28/2022] Open
Affiliation(s)
- K I Albers
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands. .,Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - C H Martini
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - G J Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - M C Warlé
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
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Geerdink RJ, Hennus MP, Westerlaken GH, Abrahams AC, Albers KI, Walk J, Wesselink E, Janssen R, Bont L, Meyaard L. LAIR-1 limits neutrophil extracellular trap formation in viral bronchiolitis. J Allergy Clin Immunol 2018; 141:811-814. [DOI: 10.1016/j.jaci.2017.08.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/27/2017] [Accepted: 08/04/2017] [Indexed: 10/18/2022]
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Maretto F, Vennik M, Albers KI, van Duijn B. TNFα secretion of monocytes exposed to pulsed radiofrequency treatment: a possible working mechanism of PRF chronic pain management. Pain Pract 2013; 14:399-404. [PMID: 23875895 DOI: 10.1111/papr.12101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Accepted: 06/27/2013] [Indexed: 12/31/2022]
Abstract
Pulsed radiofrequency treatment (PRF) is a promising new technique increasingly used in treatment of chronic pain. The molecular working mechanism of PRF is not exactly known and is currently being investigated. This study investigates a possible role of PRF-induced modulation of TNFα secretion by differentiated monocytes in chronic pain management. The results show no significant PRF-induced change in TNFα secretion of lipopolysaccharides (LPS)-stimulated monocytes. However, PRF does significantly increase TNFα secretion of differentiated monocytes that have not been stimulated with LPS. This may indicate a possible role of PRF treatment in increasing TNFα production of nonstimulated monocytes. More research is needed to determine whether this is truly a part of the working mechanism of PRF in chronic pain management and which other factors are involved.
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