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British Journal of Anaesthesia Feb 2017Dexmedetomidine has been proposed as a perineural local anaesthetic (LA) adjunct to prolong peripheral nerve block duration; however, results from our previous... (Meta-Analysis)
Meta-Analysis Review
Evidence basis for using perineural dexmedetomidine to enhance the quality of brachial plexus nerve blocks: a systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Dexmedetomidine has been proposed as a perineural local anaesthetic (LA) adjunct to prolong peripheral nerve block duration; however, results from our previous meta-analysis in the setting of brachial plexus block (BPB) did not support its use. Many additional randomized trials have since been published. We thus conducted an updated meta-analysis.
METHODS
Randomized trials investigating the addition of dexmedetomidine to LA compared with LA alone (Control) in BPB for upper extremity surgery were sought. Sensory and motor block duration, onset times, duration of analgesia, analgesic consumption, pain severity, patient satisfaction, and dexmedetomidine-related side-effects were analysed using random-effects modeling. We used ratio-of-means (lower confidence interval [point estimate]) for continuous outcomes.
RESULTS
We identified 32 trials (2007 patients), and found that dexmedetomidine prolonged sensory block (at least 57%, P < 0.0001), motor block (at least 58%, P < 0.0001), and analgesia (at least 63%, P < 0.0001) duration. Dexmedetomidine expedited onset for both sensory (at least 40%, P < 0.0001) and motor (at least 39%, P < 0.0001) blocks. Dexmedetomidine also reduced postoperative oral morphine consumption by 10.2mg [-15.3, -5.2] (P < 0.0001), improved pain control, and enhanced satisfaction. In contrast, dexmedetomidine increased odds of bradycardia (3.3 [0.8, 13.5](P = 0.0002)), and hypotension (5.4 [2.7, 11.0] (P < 0.0001)). A 50-60µg dexmedetomidine dose maximized sensory block duration while minimizing haemodynamic side-effects. No patients experienced any neurologic sequelae. Evidence quality for sensory block was high according to the GRADE system.
CONCLUSIONS
New evidence now indicates that perineural dexmedetomidine improves BPB onset, quality, and analgesia. However, these benefits should be weighed against increased risks of motor block prolongation and transient bradycardia and hypotension.
Topics: Anesthetics, Local; Brachial Plexus Block; Dexmedetomidine; Humans; Randomized Controlled Trials as Topic
PubMed: 28100520
DOI: 10.1093/bja/aew411 -
Updates in Surgery Jan 2024Pancreatic cancer is a malignant disease with a dismal prognosis. While neoadjuvant therapy has shown promise in the treatment of pancreatic cancer, its role remains a... (Meta-Analysis)
Meta-Analysis Review
Pancreatic cancer is a malignant disease with a dismal prognosis. While neoadjuvant therapy has shown promise in the treatment of pancreatic cancer, its role remains a subject of controversy among physicians. We aimed to evaluate the benefits of neoadjuvant therapy in patients with resectable and borderline resectable pancreatic cancer. Eligible studies were identified from MEDLINE, Embase, Cochrane Library, and Web of Science. Studies comparing neoadjuvant therapy with upfront surgery (with or without adjuvant therapy) in resectable and borderline resectable pancreatic cancer were included. The primary endpoint assessed was overall survival. A total of 10,022 studies were identified, and the meta-analysis finally enrolled 50 revealed studies. The meta-analysis suggested that neoadjuvant therapy significantly improved the overall survival (HR 0.74, p < 0.001) and recurrence-free survival (HR 0.75, p = 0.006) compared to the upfront surgery approach. Furthermore, neoadjuvant therapy leads to favorable postoperative outcomes, with an enhanced R0 resection rate (OR 1.90, p < 0.001) and reduced lymph node metastasis (OR 0.36, p < 0.001) and perineural invasion (OR 0.42, p < 0.001), although it is associated with a reduced resection rate (OR 0.42, p < 0.001). In addition, patients treated with neoadjuvant therapy experience superior survival benefits compared to those undergoing adjuvant therapy (HR 0.87, p = 0.019). These results are further corroborated by the subgroup analysis of randomized controlled trials. Neoadjuvant therapy has the potential to provide survival benefits and improve postoperative long-term outcomes for patients with resectable and borderline resectable pancreatic cancer. However, to validate and reinforce these findings, further well-designed and large trials are required.
Topics: Humans; Adenocarcinoma; Combined Modality Therapy; Neoadjuvant Therapy; Pancreatic Neoplasms; Prognosis
PubMed: 37639177
DOI: 10.1007/s13304-023-01626-0 -
Scandinavian Journal of Pain Jan 2018Treatment of pain following major limb amputations is often a clinical challenge in a patient population consisting mainly of elderly with underlying diseases....
BACKGROUND AND AIMS
Treatment of pain following major limb amputations is often a clinical challenge in a patient population consisting mainly of elderly with underlying diseases. Literature on management of acute post-amputation pain is scarce. We performed a systematic review on this topic to evaluate the efficacy and safety of analgesic interventions for acute pain following major limb amputation.
METHODS
A literature search was performed in PubMed, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews using the following key words: [(amputation) AND (pain OR analgesi* OR pain relief)] AND (acute OR postoperative). Randomized controlled studies (RCTs) and observational studies investigating treatment of acute pain following major amputations for any indication (peripheral vascular disease, malignant disease, trauma) were included. The review was performed according to the standards described in the PRISMA statement. The Cochrane quality assessment tool was used to evaluate the risk of bias in the RCTs.
RESULTS
Nineteen studies with total of 949 patients were included. The studies were generally small and heterogeneous on outcomes, study designs and quality. There were 16 studies on epidural or continuous perineural analgesia (CPI). Based on five RCTs (n=268) and two observational studies (n=49), epidural analgesia decreased the intensity of acute stump pain as compared to systemic analgesics, during the first 24 h after the operation. Based on one study epidural analgesia caused more adverse effects like sedation, nausea and motor block than continuous perineural local anesthetic infusion. Based on one RCT (n=21) and eight observational studies (n=501) CPI seemed to decrease opioid consumption as compared to systemic analgesics only, on the first three postoperative days, and was well tolerated. Only three trials investigated systemic analgesics (oral memantine, oral gabapentine, iv ketamine). Ketamine did not decrease acute pain or opioid consumption after amputation as compared to other systemic analgesics. Gabapentin did not decrease acute pain when combined to epidural analgesia as compared to epidural analgesia and opioid treatment, and caused adverse effects.
CONCLUSIONS
The main finding of this systematic review is that evidence regarding pain management after major limb amputation is very limited. Epidural analgesia may be effective, but firm evidence is lacking. Epidural causes more adverse effects than CPI. The results on efficacy of CPI are indecisive. The data on adjuvant medications combined to epidural analgesia or CPI is limited. Studies on efficacy and adverse effects of systemic analgesics for amputation pain, especially concentrating on elderly patients, are needed.
Topics: Acute Pain; Amputation, Surgical; Analgesia, Epidural; Analgesics; Chemotherapy, Adjuvant; Humans; Pain Management; Pain, Postoperative
PubMed: 29794290
DOI: 10.1515/sjpain-2017-0170 -
Regional Anesthesia and Pain Medicine Sep 2020Hallux valgus repair is associated with moderate-to-severe postoperative pain. The aim of this systematic review was to assess the available literature and develop... (Review)
Review
Hallux valgus repair is associated with moderate-to-severe postoperative pain. The aim of this systematic review was to assess the available literature and develop recommendations for optimal pain management after hallux valgus repair. A systematic review using PROcedure SPECific Postoperative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomized controlled trials (RCTs) published in the English language from inception of database to December 2019 assessing postoperative pain using analgesic, anesthetic, and surgical interventions were identified from MEDLINE, EMBASE, and Cochrane Database, among others. Of the 836 RCTs identified, 55 RCTs and 1 systematic review met our inclusion criteria. Interventions that improved postoperative pain relief included paracetamol and non-steroidal anti-inflammatory drugs or cyclo-oxygenase-2 selective inhibitors, systemic steroids, ankle block, and local anesthetic wound infiltration. Insufficient evidence was found for the use of gabapentinoids or wound infiltration with extended release bupivacaine or dexamethasone. Conflicting evidence was found for percutaneous chevron osteotomy. No evidence was found for homeopathic preparation, continuous local anesthetic wound infusion, clonidine and fentanyl as sciatic perineural adjuncts, bioabsorbable magnesium screws, and plaster slippers. No studies of sciatic nerve block met the inclusion criteria for PROSPECT methodology due to a wider scope of included surgical procedures or the lack of a control (no block) group. The analgesic regimen for hallux valgus repair should include, in the absence of contraindication, paracetamol and a non-steroidal anti-inflammatory drug or cyclo-oxygenase-2 selective inhibitor administered preoperatively or intraoperatively and continued postoperatively, along with systemic steroids, and postoperative opioids for rescue analgesia.
Topics: Analgesia; Hallux Valgus; Humans; Nerve Block; Pain Management; Pain, Postoperative
PubMed: 32595141
DOI: 10.1136/rapm-2020-101479 -
Critical Reviews in Oncology/hematology Jan 2022Although salvage surgery (SS) is considered the best curative choice in recurrent head and neck cancer, the identification of patients who can benefit the most from this... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Although salvage surgery (SS) is considered the best curative choice in recurrent head and neck cancer, the identification of patients who can benefit the most from this treatment is challenging.
METHODS
We systematically reviewed the prognostic role of pre- and post-surgery factors in patients undergoing SS for recurrent head and neck cancer (oral cavity, oropharynx, hypopharynx, and larynx).
RESULTS
Twenty-five studies met the inclusion criteria out of 1280 screened citations. Pre-surgery factors significantly associated with worse overall survival were age>60 years, advanced initial stage, early recurrence, and regional recurrence; no heterogeneity between study emerged. Among post- surgery factors, worse survival emerged for positive surgical margins, extracapsular extension and perineural invasion.
CONCLUSION
The identification of pre-surgery factors associated with poor outcomes may help the selection of the best candidate to SS; alternative treatments should be considered for high-risk patients. Post-surgery predictors of worse prognosis may guide clinicians in tailoring patients' surveillance.
Topics: Head and Neck Neoplasms; Humans; Middle Aged; Neoplasm Recurrence, Local; Neoplasm Staging; Prognosis; Retrospective Studies; Salvage Therapy
PubMed: 34843929
DOI: 10.1016/j.critrevonc.2021.103550 -
The American Journal of Surgical... Jan 2016Perineural invasion (PNI) is a possible route for metastatic spread in various cancer types, including colorectal cancer (CRC). PNI is linked to poor prognosis, but... (Meta-Analysis)
Meta-Analysis Review
Perineural invasion (PNI) is a possible route for metastatic spread in various cancer types, including colorectal cancer (CRC). PNI is linked to poor prognosis, but systematic analyses are lacking. This study systematically reviews the frequency and impact of PNI in CRC. A literature search was performed using PubMed database from inception to January 1, 2014. Data were analyzed using Review Manager 5.3. A quality assessment was performed on the basis of modified REMARK criteria. Endpoints were local recurrence (LR), 5-year disease-free survival (5yDFS), 5-year cancer-specific survival (5yCSS), and 5-year overall survival (5yOS). Meta-analysis was performed in terms of risk ratios (RR) and hazard ratios (HR) with 95% confidence interval (95% CI). In this meta-analysis, 58 articles with 22,900 patients were included. PNI was present in 18.2% of tumors. PNI is correlated with increased LR (RR 3.22, 95% CI, 2.33-4.44) and decreased 5yDFS (RR 2.35, 95% CI, 1.66-3.31), 5yCSS (RR 3.61, 95% CI, 2.76-4.72), and 5yOS (RR 2.09, 95% CI, 1.68-2.61). In multivariate analysis PNI remains an independent prognostic factor for 5yDFS, 5yCSS, and 5yOS (HR 2.35, 95% CI, 1.97-3.08; HR 1.91, 95% CI, 1.50-2.42; and HR 1.85, 95% CI, 1.63-2.12, respectively). We confirmed the strong impact of PNI for LR and survival in CRC. The prognostic value of PNI is similar to that of well-established prognostic factors as depth of invasion, differentiation grade, lymph node metastases, and lymphatic and extramural vascular invasion. Therefore, PNI should be one of the factors in the standardized reporting of CRC and might be considered a high-risk feature.
Topics: Chi-Square Distribution; Colorectal Neoplasms; Disease Progression; Disease-Free Survival; Humans; Multivariate Analysis; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Odds Ratio; Peripheral Nerves; Predictive Value of Tests; Risk Assessment; Risk Factors; Survival Analysis; Time Factors; Treatment Outcome
PubMed: 26426380
DOI: 10.1097/PAS.0000000000000518 -
Journal of the European Academy of... Sep 2021Although adjuvant radiotherapy has been used for cutaneous squamous cell carcinoma, its outcome benefits, especially for patients with clear surgical margins, have not... (Meta-Analysis)
Meta-Analysis Review
Although adjuvant radiotherapy has been used for cutaneous squamous cell carcinoma, its outcome benefits, especially for patients with clear surgical margins, have not been statistically estimated, and the characteristics that can indicate patients who require adjuvant therapy need to be validated with more evidence. We conducted a systematic review and meta-analysis of literature on the survival outcomes and prognostic factors in patients with cSCC treated by surgery with or without adjuvant radiotherapy. Twenty related studies involving 2605 patients met our inclusion criteria. The significant survival outcomes of adjuvant radiotherapy included lower recurrence (OR, 0.56; 95% CI, 0.36-0.85), longer disease-free survival (OR, 2.17; 95% CI, 1.23-3.83) and longer overall survival (OR, 2.94; 95% CI, 1.75-4.91). Significant prognostic factors for poor outcomes were perineural invasion (HR, 1.61; 95% CI, 1.24-2.09), involved surgical margins (HR, 2.34; 95% CI, 1.42-3.83) and immunosuppression (HR, 3.02; 95% CI, 2.14-4.25) while adjuvant radiotherapy significantly contributed to better overall survival (HR, 0.47; 95% CI, 0.34-0.65). In conclusion, this systematic review suggests that in cutaneous squamous cell carcinoma patients with risk factors, including metastasis to the parotid gland, perineural invasion and immunosuppression, the use of adjuvant radiotherapy may be beneficial irrespective of surgical margin status.
Topics: Carcinoma, Squamous Cell; Humans; Neoplasm Recurrence, Local; Neoplasm Staging; Prognosis; Radiotherapy, Adjuvant; Retrospective Studies; Skin Neoplasms
PubMed: 33930213
DOI: 10.1111/jdv.17330 -
Medicina Oral, Patologia Oral Y Cirugia... May 2022This study aimed to analyze whether immunohistochemistry (IHC) is more sensitive than hematoxylin-eosin (H&E) staining for identifying perineural invasion (PNI) or... (Meta-Analysis)
Meta-Analysis
Is immunohistochemistry more sensitive than hematoxylin-eosin staining for identifying perineural or lymphovascular invasion in oral squamous cell carcinoma? A systematic review and meta-analysis.
BACKGROUND
This study aimed to analyze whether immunohistochemistry (IHC) is more sensitive than hematoxylin-eosin (H&E) staining for identifying perineural invasion (PNI) or lymphovascular invasion (LVI) in oral squamous cell carcinoma (OSCC).
MATERIAL AND METHODS
In this systematic review and meta-analysis (Prospective Register of Systematic Reviews - CRD 42021256515), data were obtained from six databases (PubMed, Scopus, LILACS, Web of Science, EBSCO, LIVIVO, Embase) and the grey literature. Cross-sectional observational studies of the diagnostic sensitivity of IHC for PNI and LVI were included. Studies were selected in two phases: first collection and reference retrieval. The Quality Assessment of Diagnostic Accuracy Studies-2 tool assessed study quality, while the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach assessed evidence quality. The meta-analysis (random effects model) was performed using MedCalc 18.2.1 software (MedCalc®) (p<0.05).
RESULTS
Four studies (560 patients with 295 biopsies) were analyzed. The combined sensitivity was 76% (95% confidence interval [CI], 44.30-97.19%) and specificity was 42% (95% CI, 23.40-62.02%). The positive predictive value (PPV) and negative predictive value (NPV) were 61% (95% CI, 49.78-71.53%) and 70% (95% CI, 37.63-94.43%). The overall accuracy was 58% (95% CI, 45.17-70.65%). The risk of bias was low, and GRADE analysis showed a very low certainty of evidence.
CONCLUSIONS
Our data suggest that IHC staining to highlight PNI/LVI may be useful in cases in which H&E analysis results in a negative decrease in the prevalence of false-negative cases and underestimated treatment.
Topics: Carcinoma, Squamous Cell; Cross-Sectional Studies; Eosine Yellowish-(YS); Head and Neck Neoplasms; Hematoxylin; Humans; Immunohistochemistry; Lymphatic Metastasis; Mouth Neoplasms; Neoplasm Invasiveness; Squamous Cell Carcinoma of Head and Neck; Staining and Labeling
PubMed: 35420066
DOI: 10.4317/medoral.25114 -
Head & Neck Apr 2016Perineural invasion (PNI) is widely regarded as a negative prognostic factor in head and neck squamous cell carcinoma (HNSCC). Treatment guidelines recommend adjuvant... (Review)
Review
Perineural invasion (PNI) is widely regarded as a negative prognostic factor in head and neck squamous cell carcinoma (HNSCC). Treatment guidelines recommend adjuvant radiotherapy (RT) for patients with adverse pathologic features, including PNI. The purpose of this study was to systematically review the literature to determine if patients with PNI as their only indication for adjuvant therapy benefit from adjuvant RT. In total, 339 abstracts were reviewed for relevance leaving 85 articles, which were evaluated in detail. Thirteen retrospective studies addressed the role of adjuvant RT for patients with PNI. Evidence is lacking to recommend adjuvant RT for all patients with HNSCC with PNI. However, the literature suggests that large nerve or multifocal PNI may predict worse outcome and may be a more appropriate indication for adjuvant therapy. We advocate that patients decide whether to undergo adjuvant therapy after a discussion of the limitations of current evidence. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2350-E2357, 2016.
Topics: Carcinoma, Squamous Cell; Head and Neck Neoplasms; Humans; Neoplasm Invasiveness; Peripheral Nerves; Prognosis; Radiotherapy, Adjuvant; Retrospective Studies
PubMed: 26613965
DOI: 10.1002/hed.24295 -
BMC Urology Feb 2018Although numerous studies have shown that perineural invasion (PNI) is linked to prostate cancer (PCa) risk, the results have been inconsistent. This study aimed to... (Meta-Analysis)
Meta-Analysis Review
Perineural invasion as an independent predictor of biochemical recurrence in prostate cancer following radical prostatectomy or radiotherapy: a systematic review and meta-analysis.
BACKGROUND
Although numerous studies have shown that perineural invasion (PNI) is linked to prostate cancer (PCa) risk, the results have been inconsistent. This study aimed to explore the association between PNI and biochemical recurrence (BCR) in patients with PCa following radical prostatectomy (RP) or radiotherapy (RT).
METHODS
According to the PRISMA statement, we searched the PubMed, EMBASE, Chinese National Knowledge Infrastructure (CNKI) and Wan Fang databases from inception to May 2017. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were extracted from eligible studies. Fixed or random effects model were used to calculate pooled HRs and 95% CIs according to heterogeneity. Publication bias was calculated by Begg's test.
RESULTS
Ultimately, 19 cohort studies that met the eligibility criteria and that involved 13,412 patients (82-2,316 per study) were included in this meta-analysis. The results showed that PNI was associated with higher BCR rates in patients with PCa after RP (HR=1.23, 95% CI: 1.11, 1.36, p<0.001) or RT (HR=1.22, 95% CI: 1.12, 1.34, p<0.001). No potential publication bias was found among the included studies in the RP group (p-Begg = 0.124) or the RT group (p-Begg = 0.081).
CONCLUSIONS
This study suggests that the presence of PNI by histopathology is associated with higher risk of BCR in PCa following RP or RT, and could serve as an independent prognostic factor in patients with PCa.
Topics: Humans; Male; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Peripheral Nerves; Predictive Value of Tests; Prostatectomy; Prostatic Neoplasms
PubMed: 29390991
DOI: 10.1186/s12894-018-0319-6