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International Journal of Surgery... Nov 2023The optimal approach for perioperative pain management in laparoscopic gynecological surgery is unclear due to a lack of comprehensive analysis, which limits the... (Meta-Analysis)
Meta-Analysis
Efficacy of nonopioid analgesics and regional techniques for perioperative pain management in laparoscopic gynecological surgery: a systematic review and network meta-analysis.
BACKGROUND
The optimal approach for perioperative pain management in laparoscopic gynecological surgery is unclear due to a lack of comprehensive analysis, which limits the development of evidence-based enhanced recovery after surgery protocols. This study aimed to conduct a systematic review and network meta-analysis to support clinical decision-making for optimal analgesia.
MATERIALS AND METHODS
This study conducted a systematic literature search in PubMed, Embase, CENTRAL, Web of Science, and CINAHL from inception to 3 December 2021, and updated on 19 August 2022. Randomized controlled trials comparing the perioperative use of nonopioid analgesics and regional techniques in adults undergoing elective laparoscopic gynecological surgery under general anesthesia were included in the analysis, either alone or in combination. The co-analgesic interventions during the perioperative period for the intervention and control groups of each eligible study were also considered. We assessed the risk of bias using the Risk of Bias 2 tool and evaluated the certainty of evidence using the Confidence in Network Meta-Analysis (CINeMA) approach. A Bayesian network meta-analysis was used to estimate the efficacy of the analgesic strategies. The primary outcomes were pain score at rest and cumulative oral morphine milligram equivalents at 24 h postoperatively.
RESULTS
Overall, 108 studies with 9582 participants and 35 different interventions were included. Compared with inert treatments, combinations of two or more interventions showed better efficacy and longer duration in reducing postoperative pain and opioid consumption within 24 h than monotherapies, and showed stepwise enhanced effects with increasing analgesic modes. In combination therapies, regional techniques that included peripheral nerve blocks and intraperitoneal local anesthetics, in combination with nonopioid systemic analgesics, or combining local anesthetics with adjuvant drugs, were found to be more effective. Monotherapies were found to be mostly ineffective. The most effective peripheral nerve blocks were found to be ultrasound-guided transversus abdominis plane block with adjuvant and ultrasound-guided quadratus lumborum block.
CONCLUSIONS
These results provide robust evidence for the routine use of regional techniques in combination with nonopioid analgesics in perioperative pain management. However, further better quality and larger trials are needed, considering the low confidence levels for certain interventions.
Topics: Adult; Humans; Female; Anesthetics, Local; Pain Management; Analgesics, Non-Narcotic; Network Meta-Analysis; Bayes Theorem; Analgesics; Analgesics, Opioid; Pain, Postoperative; Laparoscopy; Gynecologic Surgical Procedures
PubMed: 37534670
DOI: 10.1097/JS9.0000000000000630 -
Journal of Personalized Medicine Oct 2023The analgesia nociception index (ANI) has emerged as a potential measurement for objective pain assessment during general anesthesia. This systematic review and... (Review)
Review
The analgesia nociception index (ANI) has emerged as a potential measurement for objective pain assessment during general anesthesia. This systematic review and meta-analysis aimed to evaluate the accuracy and effectiveness of ANI in assessing intra- and post-operative pain in patients undergoing general anesthesia. We conducted a comprehensive search of Ovid-MEDLINE, Ovid-EMBASE, Cochrane Central Register of Controlled Trials, Google Scholar, public clinical trial databases (ClinicalTrials and Clinical Research Information Service), and OpenSIGLE to identify relevant studies published prior to May 2023 and included studies that evaluated the accuracy and effectiveness of ANI for intra- or post-operative pain assessment during general anesthesia. Among the 962 studies identified, 30 met the eligibility criteria and were included in the systematic review, and 17 were included in the meta-analysis. For predicting intra-operative pain, pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under curve of ANI were 0.81 (95% confidence interval [CI] = 0.79-0.83; I = 68.2%), 0.93 (95% CI = 0.92-0.93; I = 99.8%), 2.32 (95% CI = 1.33-3.30; I = 61.7%), and 0.77 (95% CI = 0.76-0.78; I = 87.4%), respectively. ANI values and changes in intra-operative hemodynamic variables showed statistically significant correlations. For predicting post-operative pain, pooled sensitivity, specificity, and DOR of ANI were 0.90 (95% CI = 0.87-0.93; I = 58.7%), 0.51 (95% CI = 0.49-0.52; I = 99.9%), and 3.38 (95% CI = 2.87-3.88; I = 81.2%), respectively. ANI monitoring in patients undergoing surgery under general anesthesia is a valuable measurement for predicting intra- and post-operative pain. It reduces the use of intra-operative opioids and aids in pain management throughout the perioperative period.
PubMed: 37888072
DOI: 10.3390/jpm13101461 -
Brazilian Journal of Cardiovascular... Feb 2024This study aimed to evaluate the efficacy of respiratory muscle training during the immediate postoperative period of cardiac surgery on respiratory muscle strength,... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
This study aimed to evaluate the efficacy of respiratory muscle training during the immediate postoperative period of cardiac surgery on respiratory muscle strength, pulmonary function, functional capacity, and length of hospital stay.
METHODS
This is a systematic review and meta-analysis. A comprehensive search on PubMed®, Excerpta Medica Database (or Embase), Cumulative Index of Nursing and Allied Health Literature (or CINAHL), Latin American and Caribbean Health Sciences Literature (or LILACS), Scientific Electronic Library Online (or SciELO), Physiotherapy Evidence Database (or PEDro), and Cochrane Central Register of Controlled Trials databases was performed. A combination of free-text words and indexed terms referring to cardiac surgery, coronary artery bypass grafting, respiratory muscle training, and clinical trials was used. A total of 792 studies were identified; after careful selection, six studies were evaluated.
RESULTS
The studies found significant improvement after inspiratory muscle training (IMT) (n = 165, 95% confidence interval [CI] 9.68, 21.99) and expiratory muscle training (EMT) (n = 135, 95% CI 8.59, 27.07) of maximal inspiratory pressure and maximal expiratory pressure, respectively. Also, IMT increased significantly (95% CI 19.59, 349.82, n = 85) the tidal volume. However, no differences were found in the peak expiratory flow, functional capacity, and length of hospital stay after EMT and IMT.
CONCLUSION
IMT and EMT demonstrated efficacy in improving respiratory muscle strength during the immediate postoperative period of cardiac surgery. There was no evidence indicating the efficacy of IMT for pulmonary function and length of hospital stay and the efficacy of EMT for functional capacity.
Topics: Humans; Cardiac Surgical Procedures; Breathing Exercises; Lung; Coronary Artery Bypass; Respiratory Muscles; Muscle Strength
PubMed: 38315040
DOI: 10.21470/1678-9741-2022-0165 -
Surgery Dec 2023The benefits of immunonutrition in patients who underwent major abdominal surgery have been recently established, but the optimal combination of immunonutrients has... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The benefits of immunonutrition in patients who underwent major abdominal surgery have been recently established, but the optimal combination of immunonutrients has remained unclear. The aim is to clarify this point.
METHODS
A systematic search of randomized clinical trials about immunonutrition in major abdominal surgery was made. A frequentist random-effects component network meta-analysis was conducted, reporting the P score and odds ratio or mean difference with a 95% confidence interval. The best components and best plausible strategies were described. The critical endpoints were morbidity and mortality rates. The important endpoints were infectious complication rate and length of stay.
RESULTS
The meta-analysis includes 87 studies and 8,375 patients. The best approach for morbidity rate, with a moderate grade of certainty, was the use of perioperative enteral/oral immunonutrition with arginine, glutamine, and polyunsaturated fatty acids (odds ratio 0.32; 0.10 to 0.98; P score of 0.93). The mortality rate was reduced by postoperative enteral immunonutrition with RNA, arginine, and polyunsaturated fatty acids (odds ratio 59; 0.29 to 1.22; P score 0.84) but with a low grade of certainty. No significant heterogeneity or incoherence is observed. The length of stay and infectious results are "at risk" for high heterogeneity or network meta-analysis incoherence. The component analysis confirmed that postoperative oral/enteral use of 2 or 3 components is crucial to reducing morbidity rate.
CONCLUSION
The oral/enteral immunonutrition in the postoperative period, with multiple immunonutrients, can reduce the morbidity rate in patients undergoing major abdominal surgery. The effect of immunonutrition on mortality, infectious disease, and length of stay is unclear.
Topics: Humans; Immunonutrition Diet; Motion Pictures; Abdomen; Arginine; Fatty Acids, Unsaturated
PubMed: 37775395
DOI: 10.1016/j.surg.2023.08.005 -
The Journal of Arthroplasty May 2024The aim of this study was to investigate the safety of early surgery in hip fracture patients who took clopidogrel and/or aspirin. (Meta-Analysis)
Meta-Analysis
BACKGROUND
The aim of this study was to investigate the safety of early surgery in hip fracture patients who took clopidogrel and/or aspirin.
METHODS
A systematic search was conducted using databases, including PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science, for studies relating to early arthroplasty or internal fixation for femoral neck fractures, intertrochanteric fractures, and subtrochanteric fractures in patients taking clopidogrel and/or aspirin. A total of 20 observational studies involving 3,077 patients were included in this meta-analysis, and analyzed in groups of early surgery versus delayed surgery, and clopidogrel and/or aspirin versus nonantiplatelet agents.
RESULTS
Patients in the clopidogrel and/or aspirin group who underwent early surgery had significantly more intraoperative blood loss than those in the non-antiplatelet group (mean difference = 17.96, 95% confidence interval [CI] [4.37, 31.55], P = .01), and patients in the clopidogrel and/or aspirin group had a lower overall incidence of complications after early surgery than those in the delayed surgery group (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001) and a shorter length of hospital stay (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001). There was no significant difference in postoperative mortality and other related indicators.
CONCLUSIONS
Early surgery in hip fracture patients taking clopidogrel and/or aspirin appears to be safe based on the available evidence and needs to be clarified by higher quality studies. However, the increased risk of cardiovascular events associated with discontinuation of clopidogrel or clopidogrel combined with aspirin dual antiplatelet therapy requires attention in the perioperative period.
Topics: Humans; Clopidogrel; Aspirin; Platelet Aggregation Inhibitors; Hip Fractures; Femoral Neck Fractures; Observational Studies as Topic
PubMed: 37972664
DOI: 10.1016/j.arth.2023.11.012 -
Neurosurgical Review Sep 2023Optic canal unroofing (OCU) has gradually become a routine technique for tuberculum sellae meningiomas (TSMs) resection. This meta-analysis aimed to evaluate the... (Meta-Analysis)
Meta-Analysis Review
Optic canal unroofing (OCU) has gradually become a routine technique for tuberculum sellae meningiomas (TSMs) resection. This meta-analysis aimed to evaluate the efficacy and safety of OCU. A systematic review and meta-analysis of the published literature on this topic from 2003 to 2023 were conducted in accordance with the PRISMA guidelines. Rigorous statistical analysis with a p-value was performed for related change in visual improvement, gross total resection (GTR), visual deterioration, and olfactory nerve damage. The study included 15 articles with 384 patients in whom OCU was performed by the transcranial approach (TCA) or the endoscopic endonasal approach (EEA). Of these, 341 patients had preoperative visual loss, and 266 patients had postoperative visual recovery. The overall rate of visual improvement was 0.803 (95% CI: 0.733-0.874, p < 0.01). The rate of visual improvement in the EEA and TCA groups was 0.884 (95% CI: 0.803-0.965, p < 0.01) and 0.788 (95% CI: 0.700-0.875, p < 0.01). Further analysis of classification shows that the rate of visual improvement in Type I: < 2 cm was 0.889(95% CI: 0.739-0.969), Type II:2-4 cm was 0.844(95% CI: 0.755-0.910), Type III: > 4 cm was 0.500(95% CI: 0.068-0.932) and the total was 0.853(95% CI: 0.779-0.927 p < 0.01) with low heterogeneity of I = 20.80%.Twelve studies separately reported GTR with OCU was 293; the rate of GTR was 0.911 (95% CI: 0.848-0.961, p < 0.01). And the rate of GTR in Type I: < 2 cm was 0.933(95% CI: 0.817-0.986), Type II:2-4 cm was 0.880(95% CI: 0.800-0.936), Type III: > 4 cm was 0.600(95% CI: 0.147-0.947). The total was 0.897(95% CI: 0.830-0.965 p < 0.01) with low heterogeneity of I = 34.57%. The related complications of OCU were visual deterioration and olfactory nerve damage. Visual decline was reported in nine studies, and the rate was 0.077 (95% CI: 0.041-0.113, p < 0.01). Six studies reported olfactory nerve damage, and the overall rate was 0.054 (95% CI: 0.019-0.090, p < 0.01). OCU could significantly recover preoperative impaired vision and make GTR easier to achieve, which was also a safe and effective technique in TSM.
Topics: Humans; Meningioma; Postoperative Period; Skull Base Neoplasms; Meningeal Neoplasms
PubMed: 37698750
DOI: 10.1007/s10143-023-02151-9 -
BMC Anesthesiology Nov 2023The latest clinical trials have reported conflicting outcomes regarding the effectiveness of xenon anesthesia in preventing postoperative neurocognitive dysfunction;... (Meta-Analysis)
Meta-Analysis
The latest clinical trials have reported conflicting outcomes regarding the effectiveness of xenon anesthesia in preventing postoperative neurocognitive dysfunction; thus, this study assessed the existing evidence. We searched the PubMed, Embase, Cochrane Library, and Web of Science databases from inception to April 9, 2023, for randomized controlled trials of xenon anesthesia in postoperative patients. We included English-language randomized controlled studies of adult patients undergoing surgery with xenon anesthesia that compared its effects to those of other anesthetics. Duplicate studies, pediatric studies, and ongoing clinical trials were excluded. Nine studies with 754 participants were identified. A forest plot revealed that the incidence of postoperative neurocognitive dysfunction did not differ between the xenon anesthesia and control groups (P = 0.43). Additionally, xenon anesthesia significantly shortened the emergence time for time to opening eyes (P < 0.001), time to extubation (P < 0.001), time to react on demand (P = 0.01), and time to time and spatial orientation (P = 0.04). However, the Aldrete score significantly increased with xenon anesthesia (P = 0.005). Postoperative complications did not differ between the anesthesia groups. Egger's test for bias showed no small-study effect, and a trim-and-fill analysis showed no apparent publication bias. In conclusion, xenon anesthesia probably did not affect the occurrence of postoperative neurocognitive dysfunction. However, xenon anesthesia may effectively shorten the emergence time of certain parameters without adverse effects.
Topics: Adult; Humans; Child; Xenon; Postoperative Period; Anesthetics; Anesthesia, Inhalation; Delirium
PubMed: 37946114
DOI: 10.1186/s12871-023-02316-5 -
Journal of Clinical Medicine Sep 2023The development of prolonged post-operative ileus (POI) remains a significant problem in the general surgical patient population. The aetiology of ileus is poorly... (Review)
Review
BACKGROUND
The development of prolonged post-operative ileus (POI) remains a significant problem in the general surgical patient population. The aetiology of ileus is poorly understood and management options/preventative measures are currently extremely limited. The pathophysiology leading to a post-operative ileus is relatively poorly understood, and there is no validated method to estimate ileus occurrence or duration. Ileus in the post-operative period commonly occurs following major colorectal surgery and leads to painful abdominal distension, vomiting, nutritional deficit, pneumonia, prolonged hospital stays and susceptibility to hospital-acquired infection. An increased hospital stay, the burden of treatment costs and the burden on the health system highlight the importance of future research on finding definitions, preventions and predictions of ileus.
METHODS
A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing the rate of ileus on various treatments for prolonged post-operative ileus following colorectal surgery. A confidence evaluation in a meta-analysis were performed using CINeMA. Direct and indirect comparisons of all interventions were simultaneously carried out using a network meta-analysis. The level of certainty was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. The method of assessing the risk of bias, the quality assessment, used the Cochrane Risk of Bias 2 tool (RoB2).
RESULTS
Among the seven included studies, the majority suffered from considerable within-study bias, affecting the confidence rates of study findings. Heterogeneity and incoherence made the pairwise meta-analysis and ranking of interventions unfeasible. Indirect comparisons were considered unreliable due to this incoherence.
CONCLUSIONS
This systematic review, with a confidence evaluation in the network meta-analysis, determined that there is a knowledge gap in the field of study on prolonged ileus following digestive surgery. The current evidence suffers from heterogeneity and incoherence more than imprecision. There is a gap in the data on ileus occurrence in interventional trials for digestive surgery. This could inform clinicians and trialists to better appraise the current literature and plan future trials.
PubMed: 37762711
DOI: 10.3390/jcm12185769 -
Cureus May 2024Transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) represents a minimally invasive alternative to traditional open thyroidectomy (OT). The objective... (Review)
Review
Transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) represents a minimally invasive alternative to traditional open thyroidectomy (OT). The objective of this systematic review and meta-analysis was to comprehensively analyze and compare postoperative pain outcomes between conventional open thyroidectomy (COT) and TOETVA. We conducted a systematic search across multiple databases, including PubMed, Medline, Elton B. Stephens Company (EBSCO), and Google Scholar, to identify cohorts and randomized trials comparing postoperative pain outcomes between patients undergoing transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) and those undergoing conventional thyroidectomy. The search period spanned from the earliest available article up to January 15, 2022. Keywords such as "scarless thyroidectomy," "endoscopic transoral via vestibular thyroidectomy," "conventional thyroidectomy," "transcervical thyroidectomy," "postoperative pain," and "visual analog pain score" were utilized to retrieve relevant studies. A total of 1,291 patients from 11 studies were included in our analysis, with 10 studies originating from Asia and one from Europe. Among these studies, seven were prospective, while four were retrospective. The primary outcome measure was postoperative pain. Various statistical tests were also performed for data analysis, including the Chi-square and random effects model. The Newcastle Ottawa Scale was used to assess the quality of studies. There was no significant statistical difference observed between the endoscopic transoral vestibular route and the conventional cervical approach in terms of visual analog scale (VAS) score, with an odds ratio of -0.37 and a 95% confidence interval ranging from -0.9 to 0.17. The overall effect had a P-value of 0.18. However, substantial heterogeneity was noted, with an I2 value for heterogeneity of 98% and a P-value for heterogeneity of less than 0.001. The Chi-square value was calculated as 364.02, and the main difference was 9. In comparison, TOETVA exhibited lower pain levels on the first day post-operation compared to conventional thyroidectomy, with an odds ratio of -1.36 and a 95% confidence interval ranging from -2.65 to -0.06. Transoral endoscopic thyroidectomy via the vestibular approach demonstrated superior outcomes compared to conventional thyroidectomy in terms of postoperative pain management on the first day following surgery. However, when considering overall pain management throughout the recovery period, no significant difference was observed between the two approaches. More extensive studies evaluating pain levels on the day of surgery and controlling for analgesic interventions are warranted.
PubMed: 38854204
DOI: 10.7759/cureus.59998 -
World Journal of Surgical Oncology Feb 2024Direct oral anticoagulants (DOACs) used as an alternative to low-molecular-weight heparin (LMWH) for thromboprophylaxis after cancer surgery for venous thromboembolic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Direct oral anticoagulants (DOACs) used as an alternative to low-molecular-weight heparin (LMWH) for thromboprophylaxis after cancer surgery for venous thromboembolic events (VTE) remains unclear. This study aimed to investigate the efficacy and safety of DOACs versus LMWH in these patients.
MATERIALS AND METHODS
A search of EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science was carried out and included all randomized controlled trials (RCTs) and observational studies that directly compared DOACs with LMWH for thromboprophylaxis in patients after cancer surgery through July 25, 2023. The primary efficacy and safety outcomes were VTE, major bleeding, and clinically relevant non-major bleeding (CRNMB) within 30 days of surgery. The risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB2) tool for RCTs and ROBINS-I tool for non-randomized studies. This study was registered in PROSPERO (CRD42023445386).
RESULTS
We retrieved 5149articles, selected 27 for eligibility, and included 10 studies (three RCTs and seven observational studies) encompassing 3054 patients who underwent postoperative thromboprophylaxis with DOACs (41%) or LMWH (59%). Compared to LMWH thromboprophylaxis, DOACs had a comparable risk of VTE (RR:0.69[95% CI:0.46-1.02], I = 0%), major bleeding (RR:1.55 [95% CI:0.82-2.93], I = 2%), and CRNMB (RR, 0.89 [95% CI, 0.4-1.98], I = 31%) during the 30-day postoperative period. Subgroup analysis of VTE and major bleeding suggested no differences according to study type, extended thromboprophylaxis, tumor types, or different types of DOAC.
CONCLUSION
DOACs are potentially effective alternatives to LMWH for thromboprophylaxis in patients undergoing cancer surgery, without increasing the risk of major bleeding events.
Topics: Humans; Heparin, Low-Molecular-Weight; Anticoagulants; Venous Thromboembolism; Hemorrhage; Neoplasms
PubMed: 38403630
DOI: 10.1186/s12957-024-03341-5