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International Journal of Surgery... Jun 2024
PubMed: 38833364
DOI: 10.1097/JS9.0000000000001737 -
International Journal of Surgery... May 2024
Letter to the editor for the article "Pharmacologic prevention and therapy of postoperative paralytic ileus after gastrointestinal cancer surgery - systematic review and meta-analysis".
PubMed: 38729113
DOI: 10.1097/JS9.0000000000001566 -
Current Oncology (Toronto, Ont.) Mar 2024Neuroendocrine prostate cancer (NEPC) is a rare subtype of prostate cancer (PCa) that usually results in poor clinical outcomes and may be accompanied by paraneoplastic... (Review)
Review
Neuroendocrine prostate cancer (NEPC) is a rare subtype of prostate cancer (PCa) that usually results in poor clinical outcomes and may be accompanied by paraneoplastic syndromes (PNS). NEPC is becoming more frequent. It can initially manifest as PNS, complicating diagnosis. Therefore, we reviewed the literature on the different PNS associated with NEPC. We systematically reviewed English-language articles from January 2017 to September 2023, identifying 17 studies meeting PRISMA guidelines for NEPC and associated PNS. A total of 17 articles were included in the review. Among these, Cushing's Syndrome (CS) due to ectopic Adrenocorticotropic hormone (ACTH) secretion was the most commonly reported PNS. Other PNS included syndrome of inappropriate Anti-Diuretic Hormone secretion (SIADH), Anti-Hu-mediated chronic intestinal pseudo-obstruction (CIPO), limbic encephalitis, Evans Syndrome, hypercalcemia, dermatomyositis, and polycythemia. Many patients had a history of prostate adenocarcinoma treated with androgen deprivation therapy (ADT) before neuroendocrine features developed. The mean age was 65.5 years, with a maximum survival of 9 months post-diagnosis. NEPC is becoming an increasingly more common subtype of PCa that can result in various PNS. This makes the diagnosis and treatment of NEPC challenging. Further research is crucial to understanding these syndromes and developing standardized, targeted treatments to improve patient survival.
Topics: Male; Humans; Aged; Prostatic Neoplasms; Androgen Antagonists; Paraneoplastic Syndromes
PubMed: 38534956
DOI: 10.3390/curroncol31030123 -
International Journal of Surgery... Mar 2024Postoperative paralytic ileus (POI) is a significant concern following gastrointestinal tumor surgery. Effective preventive and therapeutic strategies are crucial but...
BACKGROUND
Postoperative paralytic ileus (POI) is a significant concern following gastrointestinal tumor surgery. Effective preventive and therapeutic strategies are crucial but remain elusive. Current evidence from randomized-controlled trials on pharmacological interventions for prevention or treatment of POI are systematically reviewed to guide clinical practice and future research.
MATERIALS AND METHODS
Literature was systematically searched for prospective randomized-controlled trials testing pharmacological interventions for prevention or treatment of POI after gastrointestinal tumor surgery. Meta-analysis was performed using a random effects model to determine risk ratios and mean differences with 95% confidence intervals. Risk of bias and evidence quality were assessed.
RESULTS
Results from 55 studies, involving 5078 patients who received experimental interventions, indicate that approaches of opioid-sparing analgesia, peripheral opioid antagonism, reduction of sympathetic hyperreactivity, and early use of laxatives effectively prevent POI. Perioperative oral Alvimopan or intravenous administration of Lidocaine or Dexmedetomidine, while safe regarding cardio-pulmonary complications, demonstrated effectiveness concerning various aspects of postoperative bowel recovery (Lidocaine: -5.97 [-7.20 - -4.74]h, P<0.0001; Dexmedetomidine: -13.00 [-24.87 - -1.14]h, P=0.03 for time to first defecation; Alvimopan: -15.33 [-21.22 - -9.44]h, P<0.0001 for time to GI-2) and length of hospitalization (Lidocaine: -0.67 [-1.24 - -0.09]d, P=0.02; Dexmedetomidine: -1.28 [-1.96 - -0.60]d, P=0.0002; Alvimopan: -0.58 [-0.84 - -0.32]d, P<0.0001) across wide ranges of evidence quality. Perioperative non-opioid analgesic use showed efficacy concerning bowel recovery as well as length of hospitalization (-1.29 [-1.95 - -0.62]d, P=0.0001). Laxatives showed efficacy regarding bowel movements, but not food tolerance and hospitalization. Evidence supporting pharmacological treatment for clinically evident POI is limited. Results from one single study suggest that Neostigmine reduces time to flatus and accelerates bowel movements (-37.06 [-40.26 - -33.87]h, P<0.0001 and -42.97 [-47.60 - -38.35]h, P<0.0001, respectively) with low evidence quality.
CONCLUSION
Current evidence concerning pharmacological prevention and treatment of POI following gastrointestinal tumor surgery is limited. Opioid-sparing concepts, reduction of sympathetic hyperreactivity, and laxatives should be implemented into multimodal perioperative approaches.
PubMed: 38526522
DOI: 10.1097/JS9.0000000000001393 -
Journal of Clinical Anesthesia Aug 2024Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear. (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear.
DESIGN
Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment.
SETTING
Postoperative pain treatment.
PATIENTS
Adult patients undergoing visceral cancer surgery.
INTERVENTIONS
Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques.
MEASUREMENTS
Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus.
MAIN RESULTS
59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): -1.35 to -0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: -2.34 to -1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: -1.20 to -0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: -1.34 to -0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA.
CONCLUSIONS
Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.
Topics: Humans; Pain, Postoperative; Pain Management; Randomized Controlled Trials as Topic; Analgesia, Epidural; Nerve Block; Pain Measurement; Perioperative Care; Anesthesia, Conduction
PubMed: 38484505
DOI: 10.1016/j.jclinane.2024.111438 -
Journal of Crohn's & Colitis Mar 2024To evaluate outcomes of robotic versus conventional laparoscopic colorectal resections in patients with inflammatory bowel disease (IBD).
BACKGROUND
To evaluate outcomes of robotic versus conventional laparoscopic colorectal resections in patients with inflammatory bowel disease (IBD).
METHODS
Comparative studies of robotic versus laparoscopic colorectal resections in patients with IBD were included. Primary outcome was total post-operative complication rate. Secondary outcomes included operative time, conversion to open surgery, anastomotic leaks, intra-abdominal abscess formation, ileus occurrence, surgical site infection, re-operation, re-admission rate, length of hospital stay, and 30-day mortality. Combined overall effect sizes were calculated using random-effects model and the Newcastle-Ottawa Scale was used to assess risk of bias.
RESULTS
Eleven non-randomised studies (n=5,566 patients) divided between those undergoing robotic (n=365) and conventional laparoscopic (n=5,201) surgery were included. Robotic platforms were associated with a significantly lower overall post-operative complication rate compared with laparoscopic surgery (P=0.03).Laparoscopic surgery was associated with a significantly shorter operative time (P=0.00001). No difference was found in conversion rates to open surgery (P=0.15), anastomotic leaks (P=0.84), abscess formation (P=0.21), paralytic ileus (P=0.06), surgical site infections (P=0.78), re-operation (P=0.26), re-admission rate (P=0.48), and 30-day mortality (P=1.00) between the groups.Length of hospital stay was shorter following a robotic sub-total colectomy compared with conventional laparoscopy (P=0.03).
CONCLUSION
Outcomes in the surgical management of IBD are comparable between traditional laparoscopic techniques and robotic-assisted minimally invasive surgery demonstrating the safety and feasibility of robotic platforms. Larger studies investigating the use of robotic technology in Crohn's disease and ulcerative colitis separately may be of benefit with specific focus on important IBD-related metrics.
PubMed: 38466108
DOI: 10.1093/ecco-jcc/jjae037 -
Surgical Endoscopy Apr 2024Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in multimodal pain management.
METHODS
We performed a systematic review and meta-analysis with GRADE assessment. Primary outcomes were postoperative acute pain intensity at rest/during movement after 24 h, the number of patients with block-related adverse events and the number of patients with postoperative paralytic ileus.
RESULTS
82 trials were included. Peripheral regional anaesthesia combined with general anaesthesia versus general anaesthesia may result in a slight reduction of pain intensity at rest at 24 h (mean difference (MD) - 0.72 points; 95% confidence interval (CI) - 0.91 to - 0.54; I = 97%; low-certainty evidence), which was not clinically relevant. The evidence is very uncertain regarding the effect on pain intensity during activity at 24 h (MD -0.8 points; 95%CI - 1.17 to - 0.42; I = 99%; very low-certainty evidence) and on the incidence of block-related adverse events. In contrast, neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) may reduce postoperative pain intensity at rest in a clinical relevant matter (MD - 1.19 points; 95%CI - 1.99 to - 0.39; I = 97%; low-certainty evidence), but the effect is uncertain during activity (MD - 1.13 points; 95%CI - 2.31 to 0.06; I= 95%; very low-certainty evidence). There is uncertain evidence, that neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) increases the risk for block-related adverse events (relative risk (RR) 5.11; 95%CI 1.13 to 23.03; I = 0%; very low-certainty evidence).
CONCLUSION
This meta-analysis confirms that regional anaesthesia might be an important part of multimodal postoperative analgesia in laparoscopic visceral surgery, e.g. in patients at risk for severe postoperative pain, and with large differences between surgical procedures and settings. Further research is required to evaluate the use of adjuvants and the additional benefit of regional anaesthesia in ERAS programmes.
PROTOCOL REGISTRATION
PROSPERO CRD42021258281.
Topics: Adult; Humans; Anesthesia, Conduction; Pain, Postoperative; Pain Management; Analgesia; Laparoscopy
PubMed: 38307961
DOI: 10.1007/s00464-023-10667-w -
Therapeutic Advances in Urology 2023Urothelial carcinoma can arise from the urinary bladder or from the upper urinary tract. In some instances, urinary bladder cancer (UBC) and upper tract urothelial... (Review)
Review
INTRODUCTION
Urothelial carcinoma can arise from the urinary bladder or from the upper urinary tract. In some instances, urinary bladder cancer (UBC) and upper tract urothelial carcinoma (UTUC) can be concurrently diagnosed, necessitating a combined radical cystectomy (RC) with radical nephroureterectomy (RNU). A systematic review was done on the combined procedure exploring outcomes and indications, in addition to a comparative analysis between the combined procedure and cystectomy alone.
METHODS
For the systematic review, three databases (Embase, PubMed, and Cochrane) were queried, selecting only studies that included intraoperative and perioperative data. For the comparative analysis, using the NSQIP database, CPT codes for RC and RNU were used to identify two cohorts, one with RC and RNU and one with RC alone. A descriptive analysis was performed on all preoperative variables, and propensity score matching (PSM) was performed. Postoperative events were then compared between the two matched cohorts.
RESULTS
For the systematic review, 28 relevant articles were included amounting to 947 patients who underwent the combined procedure. The most common indication was synchronous multifocal disease, the most common approach was open surgery, and the most common diversion technique was using an ileal conduit. Almost 28% of patients required blood transfusion and remained in the hospital for an average of 13 days. The most common postoperative complication was prolonged paralytic ileus. For the comparative analysis, 11,759 patients were included of which 97.5% underwent RC only and 2.5% underwent the combined procedure. After PSM, the cohort that had undergone the combined procedure showed an increased risk of renal injury, increased readmission rates, and increased reoperation rates. Whereas the cohort that had undergone RC only showed an increased risk of deep venous thrombosis (DVT), sepsis, or septic shock.
CONCLUSION
A combined RC and RNU is a treatment option for concurrent UCB and UTUC that should be cautiously utilized as it is associated with high morbidity and mortality. Patient selection, discussion of the risks and benefits of the procedure, and explanation of the available treatment options remain the most important pillars in managing patients with this complex disease.
PubMed: 37188157
DOI: 10.1177/17562872231171757 -
ANZ Journal of Surgery Sep 2023Chronic intestinal pseudo-obstruction (CIPO) may be a primary or secondary phenomenon and is often multifactorial. Treatment is largely directed at improving colonic... (Review)
Review
BACKGROUND
Chronic intestinal pseudo-obstruction (CIPO) may be a primary or secondary phenomenon and is often multifactorial. Treatment is largely directed at improving colonic motility. The use of cholinesterase inhibitors such as pyridostigmine has been hypothesized to increase acetylcholine in the bowel, improving symptoms and transit times.
METHODS
A systematic review of the use of pyridostigmine in CIPO was conducted using scientific and commercial search engines identifying scientific studies enrolling adult human subjects, published from 2000 to 2022 in the English language.
RESULTS
Four studies were identified including two randomized controlled trials (RCT) and two observational studies. The studies had heterogenous inclusion criteria, dosing regimens and reported outcomes. Two studies were identified as being at high risk of bias. All studies reported improved patient outcomes with use of pyridostigmine, and low rates (4.3%) of mild cholinergic side effects. No major side effects were reported.
CONCLUSION
The use of pyridostigmine in management of CIPO is biologically plausible due to its ability to increase colonic motility, and early studies on its role are uniformly suggestive of benefit with low side-effect profile. Four clinical studies have been conducted to date, with small sample sizes, heterogeneity and high risk of bias. Further high-quality studies are required to enable assessment of pyridostigmine's utility as an effective management strategy in CIPO.
Topics: Adult; Humans; Pyridostigmine Bromide; Gastrointestinal Motility; Intestinal Pseudo-Obstruction; Cholinesterase Inhibitors; Chronic Disease
PubMed: 37132128
DOI: 10.1111/ans.18478 -
Rheumatology (Oxford, England) Sep 2023SSc is an autoimmune disease characterized by excessive fibrosis in multiple organs, including the gastrointestinal (GI) tract. GI symptoms of SSc such as intestinal...
OBJECTIVES
SSc is an autoimmune disease characterized by excessive fibrosis in multiple organs, including the gastrointestinal (GI) tract. GI symptoms of SSc such as intestinal pseudo-obstruction (IPO) are often refractory to conventional intervention and can result in longer in-hospital stay or even increased mortality. We aimed to summarize the insights to date regarding the efficacy of IVIG against GI symptoms of SSc to unveil what we should focus on in future studies.
METHODS
Herein we report the response of GI symptoms in three cases with SSc-myositis overlap who received IVIG administration. We also conducted a systematic literature review to summarize previous reports regarding the efficacy of IVIG upon the GI manifestations of SSc, according to the PRISMA 2020 guideline.
RESULTS
The case series demonstrated remarkable and rapid improvement of GI symptoms, including IPO, after IVIG administration. The literature review revealed that previous reports also support the efficacy and safety of IVIG against GI manifestations of SSc. However, they were all retrospective studies and lacking description of the short-term outcome after IVIG administration with objective and quantitative metrics.
CONCLUSION
IVIG seems to be a promising therapeutic option for the management of GI symptoms in SSc, including IPO. Investigators should focus more on short-term outcomes to properly assess the therapeutic benefit of IVIG, ideally using reliable quantitative measures in a multicentre randomized placebo-controlled setting.
Topics: Humans; Immunoglobulins, Intravenous; Retrospective Studies; Scleroderma, Systemic; Gastrointestinal Diseases; Intestinal Pseudo-Obstruction
PubMed: 36825818
DOI: 10.1093/rheumatology/kead093