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Canadian Journal of Anaesthesia =... Jan 2022Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis.
METHODS
We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the grading of recommendations, assessment, development, and evaluation system.
RESULTS
Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr.
CONCLUSIONS
Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr.
TRIAL REGISTRATION
PROSPERO (CRD42021238916); registered 25 February 2021.
Topics: Abdominal Muscles; Adult; Analgesia, Epidural; Analgesics; Analgesics, Opioid; Humans; Laparotomy; Network Meta-Analysis; Pain, Postoperative
PubMed: 34739706
DOI: 10.1007/s12630-021-02128-6 -
Plastic and Reconstructive Surgery.... Oct 2020Transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flaps are the most common abdominally based breast reconstruction...
INTRODUCTION
Transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flaps are the most common abdominally based breast reconstruction procedures. Each technique has its advantages and disadvantages; however, how morbidity relates to satisfaction is not well-understood. Our aim was to compare complications and patient-reported outcomes following pedicled TRAM (pTRAM), free TRAM (fTRAM), and DIEP flaps to guide flap selection.
METHODS
A systematic literature search was conducted, and 2 independent reviewers identified comparative studies of abdominally based flaps. Data were extracted on patient characteristics, complications, and patient-reported outcomes. Meta-analyses were conducted using random effects modeling with the DerSimonian and Laird method.
RESULTS
The search retrieved 5090 articles, of which 18 were included in this review. pTRAM flaps trended toward a higher risk of abdominal bulge/hernia compared with DIEP flaps, particularly in low-volume hospitals. While fTRAM flaps had a higher risk of abdominal morbidity compared with DIEP flaps, relative risk decreased when obese patients were excluded and when only muscle-sparing fTRAM flaps were compared. Muscle-sparing flaps had a higher risk of flap loss than fTRAM flaps. Compared with DIEP flaps, pTRAM flaps were associated with lower general satisfaction but comparable emotional well-being.
CONCLUSIONS
Our findings indicate that safety and satisfaction following abdominally based breast reconstruction depend on flap type and patient characteristics. When possible, DIEP or muscle-sparing fTRAM flaps should be performed for obese patients to decrease the risk of abdominal bulge/hernia. Although pTRAM flaps are associated with a greater risk of flap loss, they are still an appropriate option when microsurgery is not available.
PubMed: 33173667
DOI: 10.1097/GOX.0000000000003120 -
Physiotherapy Mar 2017Age-related changes in the trunk (abdominal and lumbar multifidus) muscles and their impact on physical function of older adults are not clearly understood. (Review)
Review
BACKGROUND
Age-related changes in the trunk (abdominal and lumbar multifidus) muscles and their impact on physical function of older adults are not clearly understood.
OBJECTIVES
To systematically summarise studies of these trunk muscles in older adults.
DATA SOURCES
Cochrane Library, Pubmed, EMBASE and CINAHL were searched using terms for abdominal and MF muscles and measurement methods.
STUDY SELECTION
Two reviewers independently assessed studies and included those reporting measurements of abdominal muscles and/or MF by ultrasound, computed tomography, magnetic resonance imaging or electromyography of adults aged ≥50 years.
DATA SYNTHESIS
A best evidence synthesis was performed.
RESULTS
Best evidence synthesis revealed limited evidence for detrimental effects of ageing or spinal conditions on trunk muscles, and conflicting evidence for decreased physical activity or stroke having detrimental effects on trunk muscles. Thicknesses of rectus abdominis, internal oblique and external oblique muscles were 36% to 48% smaller for older than younger adults. Muscle quality was poorer among people with moderate-extreme low back pain and predicted physical function outcomes.
LIMITATIONS
Study heterogeneity precluded meta-analysis.
CONCLUSION
Overall, the evidence base in older people has significant limitations, so the role of physiotherapy interventions aimed at these muscles remains unclear. The results point to areas in which further research could lead to clinically useful outcomes. These include determining the role of the trunk muscles in the physical function of older adults and disease; developing and testing rehabilitation programmes for older people with spinal conditions and lower back pain; and identifying modifiable factors that could mitigate age-related changes.
Topics: Abdominal Muscles; Age Factors; Aged; Aged, 80 and over; Aging; Exercise; Female; Humans; Low Back Pain; Lumbosacral Region; Male; Middle Aged; Paraspinal Muscles; Rectus Abdominis; Sex Factors; Stroke; Torso
PubMed: 27667760
DOI: 10.1016/j.physio.2016.06.001 -
Journal of Plastic, Reconstructive &... Apr 2023Nutritional status may be impaired in patients with head and neck cancer undergoing surgical treatment, often necessitating gastrostomy tube (G-tube) placement.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Nutritional status may be impaired in patients with head and neck cancer undergoing surgical treatment, often necessitating gastrostomy tube (G-tube) placement. Identifying which patients will require a G-tube remains a challenge. This study identifies predictors of G-tube requirement in patients undergoing tumor resection and reconstruction with pedicled or free flaps.
METHODS
Systematic review of the PubMed, Cochrane, and Scopus databases was performed of English language articles, discussing risk factors of perioperative G-tube placement among patients >18 years. Data on patient, tumor, and treatment factors, as well as need for G-tube, were collected. Univariable meta-analysis was conducted to identify predictors for G-tube placement.
RESULTS
Eleven studies (1,112 patients) met inclusion criteria. Overall pooled prevalence of postoperative G-tube placement was 25%. Patients with advanced cancer stage IV/recurrence were more likely to require a G-tube (OR 2.81 [CI 1.03-7.69]; p<0.05), as were those who had undergone preoperative radiation (OR 3.55 [CI 2.03-6.20], p<0.05). Reconstruction with a radial forearm free flap was associated with a lower need for G-tube versus rectus abdominis (OR 0.25 [CI 0.08-0.83], p=0.02) and latissimus dorsi flap (OR 0.21 [CI 0.04-1.09], p=0.06). There was no difference in G-tube placement between those receiving pedicled flaps versus free flaps (OR 1.54 [CI 0.38-6.20], p=0.54).
CONCLUSIONS
Among patients with head and neck cancer undergoing resection with immediate pedicled or free flap reconstruction, advanced tumor stage and history of prior radiation therapy are associated with increased likelihood of G-tube placement. More randomized controlled trials are needed to develop a decision-making algorithm.
Topics: Humans; Gastrostomy; Plastic Surgery Procedures; Free Tissue Flaps; Head and Neck Neoplasms; Risk Factors; Retrospective Studies; Postoperative Complications
PubMed: 36780787
DOI: 10.1016/j.bjps.2022.08.040 -
Arthroscopy : the Journal of... Jul 2021To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core... (Review)
Review
A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption.
PURPOSE
To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption.
METHODS
A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported.
RESULTS
Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was "athletic pubalgia," followed by "sports hernia." Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication.
CONCLUSIONS
A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location.
LEVEL OF EVIDENCE
Level V, systematic review of Level I to V studies.
Topics: Athletic Injuries; Groin; Hernia; Humans; Rectus Abdominis; Sports
PubMed: 33845134
DOI: 10.1016/j.arthro.2021.03.049 -
Hernia : the Journal of Hernias and... Dec 2011Diastasis or divarication of the rectus abdominus muscles describes the separation of the recti, usually as a result of the linea alba thinning and stretching. This... (Review)
Review
PURPOSE
Diastasis or divarication of the rectus abdominus muscles describes the separation of the recti, usually as a result of the linea alba thinning and stretching. This review examines whether divaricated recti should be repaired and tries to establish if the inherent co-morbidity associated with surgical correction outweighs the benefits derived.
METHODS
EMBASE, MEDLINE and the Cochrane library were searched for ('divarication' OR 'diastasis') AND ('recti' OR 'rectus'). A standard data extraction form was used to extract data from each text. Due to the lack of randomised control trials, meta-analysis was not possible.
RESULTS
Seven studies report that patient satisfaction was high following surgery. The most common complication seen was the development of a seroma. Other common complications included haematomas, minor skin necrosis, wound infections, dehiscence, post-operative pain, nerve damage and recurrence, the rate of which may be as high as 40%.
CONCLUSIONS
Further studies are required to compare laparoscopic and open abdominoplasty techniques. Patients and physicians should be advised that correction is largely cosmetic, and although divarications may be unsightly they do not carry the same risks of actual herniation. Progressive techniques have resulted in risk reduction with no associated surgical mortality. However, the outcomes may be imperfect, with unsightly scarring, local sepsis and the possibility of recurrence.
Topics: Humans; Muscular Diseases; Postoperative Complications; Rectus Abdominis; Seroma; Suture Techniques; Sutures
PubMed: 21688021
DOI: 10.1007/s10029-011-0839-4 -
The Journal of Surgical Research May 2021Rectus sheath block (RSB) has been increasingly used for pain management after laparoscopic procedures but with a conflicting data on its analgesic efficacy. We... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Rectus sheath block (RSB) has been increasingly used for pain management after laparoscopic procedures but with a conflicting data on its analgesic efficacy. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of RSB in adults undergoing laparoscopic surgery.
METHODS
A systematic literature search of the PubMed, Embase, CINAHL, and Cochrane Library databases was conducted from inception through October 1, 2020, to identify trials comparing RSB with a control group in laparoscopic surgery. The primary outcome was rest pain scores at 0-2 h postoperatively. Secondary outcomes included pain scores at rest at 10-12 and 24 h postoperatively, pain scores on movement at 0-2, 10-12, and 24 h postoperatively, 24- and 48-h opioid consumption, opioid-related side effects, and RSB-associated adverse events.
RESULTS
Nine trials with 698 patients were included. RSB was associated with significantly lower rest pain scores at 0-2 h postoperatively (standardized mean difference -1.83, 95% confidence interval [-2.70, -0.96], P < 0.001, I = 95%) than control. Furthermore, RSB significantly reduced pain scores at rest at 10-12 h postoperatively and on movement at 0-2 h postoperatively, 24-h opioid consumption, and opioid-related side effects. Other secondary outcomes were similar between groups. Preoperative RSB provided better pain control compared with postoperative block administration. None of the studies reported local or systemic complications related to RSB.
CONCLUSIONS
In the setting of laparoscopic surgery, RSB improves pain control for up to 12 h postoperatively and reduces opioid consumption, without major reported adverse events.
Topics: Analgesia; Humans; Laparoscopy; Pain, Postoperative; Rectus Abdominis
PubMed: 33387729
DOI: 10.1016/j.jss.2020.12.003 -
Annales de Chirurgie Plastique Et... Nov 2020In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps...
BACKGROUND
In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients' quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction.
OBJECTIVES
This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction.
DATA SOURCES
A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits.
STUDY ELIGIBILITY CRITERIA
All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search.
PARTICIPANTS, AND INTERVENTIONS
One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed.
RESULTS
We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps.
LIMITATIONS
The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed.
CONCLUSIONS
Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.
Topics: Esthetics; Humans; Lower Extremity; Plastic Surgery Procedures; Surgical Flaps; Treatment Outcome
PubMed: 32800462
DOI: 10.1016/j.anplas.2020.07.007 -
Plastic and Reconstructive Surgery May 2016Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to compare primary closure with myocutaneous flap reconstruction of perineal defects following abdominoperineal resection or pelvic exenteration with regard to surgical-site complications.
METHODS
A comprehensive literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the MEDLINE, EMBASE, Google Scholar, and Cochrane Library databases. After data extraction from included studies, meta-analysis was performed to compare outcome parameters defining surgical-site complications of flap and primary closure.
RESULTS
Our systematic review yielded 10 eligible studies (one randomized controlled trial and nine retrospective studies) involving 566 patients (226 flaps and 340 primary closures). Eight studies described rectus abdominis myocutaneous flaps and two studies used gracilis flaps. In meta-analysis, primary closure was more than twice as likely to be associated with total perineal wound complications compared with flap closure (OR, 2.17; 95 percent CI, 1.34 to 3.14; p = 0.001). Rates of major perineal wound complications were also significantly higher in the primary closure group (OR, 3.64; 95 percent CI, 1.43 to 7.79; p = 0.005). There was no statistically significant difference between primary and flap closure for minor perineal wound complications, abdominal hernias, length of stay, or reoperation rate.
CONCLUSIONS
This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure for pelvic reconstruction. The authors' results have validated the use of myocutaneous flaps for reducing perineal morbidity following abdominoperineal resection or pelvic exenteration.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, II.
Topics: Anus Neoplasms; Female; Genital Neoplasms, Female; Genital Neoplasms, Male; Gracilis Muscle; Hernia, Abdominal; Humans; Length of Stay; Male; Myocutaneous Flap; Pelvic Exenteration; Perineum; Postoperative Complications; Randomized Controlled Trials as Topic; Plastic Surgery Procedures; Rectus Abdominis; Reoperation; Retrospective Studies; Treatment Outcome; Wound Healing
PubMed: 26796372
DOI: 10.1097/PRS.0000000000002107 -
International Journal of Colorectal... Mar 2022Parastomal hernia (PSH) is a common and serious complication in patients with enterostomy, but there is no current consensus for the risk factors for PSH from previous... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Parastomal hernia (PSH) is a common and serious complication in patients with enterostomy, but there is no current consensus for the risk factors for PSH from previous studies. Therefore, this study systematically analyzed the risk factors for PSH to provide a reference for prevention and treatment of this condition.
METHODS
Seven databases and 3 registers were systematically searched from database inception to January, 2021. Study quality was assessed by Newcastle-Ottawa Scale. Review Manager 5.3 software was used for statistical analysis. The data that could not be combined quantitatively were only analyzed qualitatively.
RESULTS
Sixteen studies with 2031 patients were included. Higher BMI (OR, 1.29; 95% CI,1.02-1.63), older age (OR, 1.04; 95% CI, 1.02-1.07), female (OR, 2.55; 95% CI,1.39-4.67), lager aperture size (OR, 2.8; 95%CI, 1.78-4.42), transperitoneal stoma creation (OR, 2.4; 95% CI, 1.33-4.35), and lager waist circumference (OR, 1.01; 95% CI,1.0-1.01) were significant risk factors for PSH. The laparoscopic approach was not a risk factor for PSH (OR, 2.09; 95% CI, 0.83-5.27). Other risk factors, including the thickness of abdominal subcutaneous fat, no mesh, a stoma not through the middle of the rectus abdominis, atrophy of left lower medial part of rectus abdominis, α1(III) procollagen expression level, emergency surgery, no preoperative stoma site marking, end colostomy, smoking, diabetes, peristomal infection, severe abdominal distention, severe cough, chronic obstructive pulmonary disease, operation time and hypertension, were significant on the multivariate analysis of each individual study.
CONCLUSIONS
The current available evidence showed that higher BMI, older age, female, larger aperture size, the creation of a transperitoneal stoma, and a larger waist circumference were independent risk factors for PSH. For factors without exact cutoff value, further explorations are needed in the future. In addition, reference to the limited number of studies in the pooled analysis, these factors still need to be interpreted carefully.
Topics: Colostomy; Enterostomy; Hernia, Ventral; Humans; Risk Factors; Surgical Mesh; Surgical Stomas
PubMed: 35028686
DOI: 10.1007/s00384-021-04068-5