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Frontiers in Cardiovascular Medicine 2023Pulmonary complications occur in a substantial proportion of patients who undergo coronary artery bypass grafting. Inspiratory muscle training (IMT), a simple,... (Review)
Review
BACKGROUND
Pulmonary complications occur in a substantial proportion of patients who undergo coronary artery bypass grafting. Inspiratory muscle training (IMT), a simple, well-tolerated physical therapy, has been proposed to reduce the risk of complications, but its efficacy remains controversial.
METHOD
Randomized controlled trials (RCTs) examining the influence of IMT on the risk of pulmonary complications after coronary artery bypass grafting were identified from PubMed, Embase, CENTRAL, CINAL, and Web of Science through March 2023. Data were meta-analyzed for the primary outcomes of pulmonary complications, defined as pneumonia, pleural effusion, and atelectasis; and in terms of the secondary outcomes of maximum inspiratory pressure, maximum expiratory pressure, length of hospitalization, 6 min walk test, and peak expiratory flow and other outcomes. Risk of bias and quality of evidence assessments were carried out using the RoB 2.0 and Grading of Recommendations Assessment, Development and Evaluation (GRADE) applied to primary outcomes of pulmonary complications.
RESULTS
Data from eight RCTs involving 755 patients were meta-analyzed. IMT was associated with a significantly lower risk of postoperative pneumonia [relative risk (RR) 0.39, 95% confidence interval (CI) 0.25-0.62, < 0.0001] and atelectasis (RR 0.43, 95% CI 0.27-0.67, = 0.0002), but not pleural effusion (RR 1.09, 95% CI 0.62-1.93, = 0.76). IMT was associated with significantly better maximum inspiratory pressure (preoperative: mean difference (MD) 16.55 cmHO, 95% CI 13.86-19.24, < 0.00001; postoperative: mean difference (MD) 8.99 cmHO, 95% CI 2.39-15.60, = 0.008) and maximum expiratory pressure (MD 7.15 cmHO, 95% CI: 1.52-12.79, = 0.01), and with significantly shorter hospitalization (MD -1.71 days, 95% CI -2.56 to -0.87, < 0.001). IMT did not significantly affect peak expiratory flow or distance traveled during the 6 min walk test.
CONCLUSIONS
The available evidence from medium and high quality trials suggests that IMT can significantly decrease the risk of pneumonia and atelectasis after coronary artery bypass grafting while shortening hospitalization and improving the strength of respiratory muscles.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/, identifier: CRD42023415817.
PubMed: 37560113
DOI: 10.3389/fcvm.2023.1223619 -
Acta Neurochirurgica Sep 2023Although there is an increasing body of evidence showing gender differences in various medical domains as well as presentation and biology of pituitary adenoma (PA),... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Although there is an increasing body of evidence showing gender differences in various medical domains as well as presentation and biology of pituitary adenoma (PA), gender differences regarding outcome of patients who underwent transsphenoidal resection of PA are poorly understood. The aim of this study was to identify gender differences in PA surgery.
METHODS
The PubMed/MEDLINE database was searched up to April 2023 to identify eligible articles. Quality appraisal and extraction were performed in duplicate.
RESULTS
A total of 40 studies including 4989 patients were included in this systematic review and meta-analysis. Our analysis showed odds ratio of postoperative biochemical remission in males vs. females of 0.83 (95% CI 0.59-1.15, P = 0.26), odds ratio of gross total resection in male vs. female patients of 0.68 (95% CI 0.34-1.39, P = 0.30), odds ratio of postoperative diabetes insipidus in male vs. female patients of 0.40 (95% CI 0.26-0.64, P < 0.0001), and a mean difference of preoperative level of prolactin in male vs. female patients of 11.62 (95% CI - 119.04-142.27, P = 0.86).
CONCLUSIONS
There was a significantly higher rate of postoperative DI in female patients after endoscopic or microscopic transsphenoidal PA surgery, and although there was some data in isolated studies suggesting influence of gender on postoperative biochemical remission, rate of GTR, and preoperative prolactin levels, these findings could not be confirmed in this meta-analysis and demonstrated no statistically significant effect. Further research is needed and future studies concerning PA surgery should report their data by gender or sexual hormones and ideally further assess their impact on PA surgery.
Topics: Humans; Male; Female; Treatment Outcome; Prolactin; Retrospective Studies; Pituitary Neoplasms; Adenoma; Hormones; Postoperative Complications
PubMed: 37555999
DOI: 10.1007/s00701-023-05726-z -
World Journal of Gastrointestinal... Jul 2023Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if...
BACKGROUND
Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages. However, the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration. Appropriate patient selection, counselling and resource allocation is essential. Numerous risk models have been devised to guide surgeons in making these decisions.
AIM
To evaluate which multivariate risk models, using intraoperative information with or without preoperative information, best predict perioperative oesophagectomy outcomes.
METHODS
A systematic review of the MEDLINE, EMBASE and Cochrane databases was undertaken from 2000-2020. The search terms used were [(Oesophagectomy) AND (Model OR Predict OR Risk OR score) AND (Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)]. Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy. Articles were excluded if they only required preoperative or any post-operative data. Studies appraising univariate risk predictors such as preoperative sarcopenia, cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded. The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model. All captured risk models were appraised for clinical credibility, methodological quality, performance, validation and clinical effectiveness.
RESULTS
Twenty published studies were identified which examined eleven multivariate risk models. Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values. Only two risk models were identified as promising in predicting mortality, namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and POSSUM scores. A further two studies, the intraoperative factors and Esophagectomy surgical Apgar score based nomograms, adequately forecasted major morbidity. The latter two models are yet to have external validation and none have been tested for clinical effectiveness.
CONCLUSION
Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes, there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.
PubMed: 37555117
DOI: 10.4240/wjgs.v15.i7.1485 -
BMJ Surgery, Interventions, & Health... 2023Surgical site infections (SSIs) are among the most common healthcare-associated infections occurring following 1%-3% of all surgical procedures. Their rates are the...
OBJECTIVE
Surgical site infections (SSIs) are among the most common healthcare-associated infections occurring following 1%-3% of all surgical procedures. Their rates are the highest following abdominal surgery. They are still associated with increased morbidity and healthcare costs despite the advancement in the medical field. Many risk factors for SSIs following abdominal surgery have been identified. The aim of this study is to comprehensively assess these risk factors as published in peer-reviewed journals.
DESIGN
A systematic review was conducted with accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.
SETTING
The databases for search were PubMed and Cochrane Library, in addition to reference lists. Studies were retrieved and assessed for their quality. Data were extracted in a designed form, and a stratified synthesis of data was conducted to report the significant risk factors.
PARTICIPANTS
Patients undergoing general abdominal surgery.
INTERVENTION
The intervention of general abdominal surgery.
MAIN OUTCOME MEASURES
To identify and assess the risk factors for SSI following abdominal surgery.
RESULTS
Literature search yielded 813 articles, and the final screening process identified 11 eligible studies. The total number of patients is 11 996. The rates of SSI ranged from 4.09% to 26.7%. Nine studies were assessed to be of high quality, the remaining two studies have moderate quality. Stratified synthesis of data was performed for risk factors using summary measures (OR/risk ratio, 95% CI, and p value). Male sex and increased body mass index (BMI) were identified as significant demographic risk factors, and long operative time was among the major significant procedure-related risk factors.
CONCLUSIONS
Male sex, increased BMI, diabetes, smoking, American Society of Anesthesiologists classification of >2, low albumin level, low haemoglobin level, preoperative hospital stay, long operative time, emergency procedure, open surgical approach, increased wound class, intraoperative blood loss, perioperative infection, perioperative blood transfusion, and use of drains are potential independent risk factors for SSI following abdominal surgery.
PubMed: 37529828
DOI: 10.1136/bmjsit-2023-000182 -
Frontiers in Oncology 2023The ongoing coronavirus disease 2019 (COVID-19) pandemic has placed unprecedented pressure on the healthcare systems. This study evaluated the safety of colorectal...
BACKGROUND
The ongoing coronavirus disease 2019 (COVID-19) pandemic has placed unprecedented pressure on the healthcare systems. This study evaluated the safety of colorectal cancer (CRC) surgery during the COVID-19 pandemic.
METHODS
A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO ID: CRD 42022327968). Relevant articles were systematically searched in the PubMed, Embase, Web of Science, and Cochrane databases. The postoperative complications, anastomotic leakage, postoperative mortality, 30-day readmission, tumor stage, total hospitalization, postoperative hospitalization, preoperative waiting, operation time, and hospitalization in the intensive care unit (ICU) were compared between the pre-pandemic and during the COVID-19 pandemic periods.
RESULTS
Among the identified 561 articles, 12 met the inclusion criteria. The data indicated that preoperative waiting time related to CRC surgery was higher during the COVID-19 pandemic (MD, 0.99; 95%CI, 0.71-1.28; p < 0.00001). A similar trend was observed for the total operative time (MD, 25.07; 95%CI, 11.14-39.00; p =0.0004), and on T4 tumor stage during the pandemic (OR, 1.77; 95%CI, 1.22-2.59; p=0.003). However, there was no difference in the postoperative complications, postoperative 90-day mortality, anastomotic leakage, and 30-day readmission times between pre-COVID-19 pandemic and during the COVID-19 pandemic periods. Furthermore, there was no difference in the total hospitalization time, postoperative hospitalization time, and hospitalization time in ICU related to CRC surgery before and during the COVID-19 pandemic.
CONCLUSION
The COVID-19 pandemic did not affect the safety of CRC surgery. The operation of CRC during the COVID-19 pandemic did not increase postoperative complications, postoperative 90-day mortality, anastomotic leakage, 30-day readmission, the total hospitalization time, postoperative hospitalization time, and postoperative ICU hospitalization time. However, the operation of CRC during COVID-19 pandemic increased T4 of tumor stage during the COVID-19 pandemic. Additionally, the preoperative waiting and operation times were longer during the COVID-19 pandemic. This provides a reference for making CRC surgical strategy in the future.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/, identifier CRD42022327968.
PubMed: 37529694
DOI: 10.3389/fonc.2023.1163333 -
Indian Journal of Thoracic and... Jul 2023Right ventricular failure (RVF) in patients with a continuous-flow left ventricle assist device (CF-LVAD) is associated with higher incidence of mortality. This... (Review)
Review
BACKGROUND
Right ventricular failure (RVF) in patients with a continuous-flow left ventricle assist device (CF-LVAD) is associated with higher incidence of mortality. This systematic review aims to assess the overall proportion of RVF and the pre-operative echocardiographic parameters which are best correlating to RVF.
METHODS
A systematic research was conducted between 2008 and 2019 on MEDLINE, EMBASE, PUBMED, UPTODATE, OVID, COCHRANE LIBRARY, and Google Scholar electronic databases by performing a PRISMA flowchart. All observational studies regarding echocardiographic predictors of RVF in patients undergoing CF-LVAD implantation were included.
RESULTS
A total number of 19 observational human studies published between 2008 and 2019 were included. We identified 524 RVF patients out of a pooled final population of 1741 patients. The RVF overall proportion was 28.25% with 95% confidence interval (CI) 0.24-0.34. The highest variability of perioperative echocardiographic parameters between the RVF and no right ventricular failure (NO-RVF) groups has been found with tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and right ventricular global longitudinal strain (RVGLS). Their standardized mean deviation (SMD) was - 0.33 (95% CI - 0.54 to - 0.11; value 0.003), - 0.34 (95% CI - 0.53 to - 0.15; value 0.0001), and 0.52 (95% CI 0.79 to 0.25; value 0.0001), respectively.
CONCLUSIONS
The echocardiographic predictors of RVF after CF-LVAD placement are still uncertain. However, there seems to be a trend of statistical correlation between TAPSE, FAC, and RVGLS with RVF event after CF-LVAD placement.
SUPPLEMENTARY INFORMATION
The online version contains supplementary material available at 10.1007/s12055-022-01447-7.
PubMed: 37525703
DOI: 10.1007/s12055-022-01447-7 -
BMC Medicine Jul 2023Prehabilitation aims at enhancing patients' functional capacity and overall health status to enable them to withstand a forthcoming stressor like surgery. Our aim was to...
BACKGROUND
Prehabilitation aims at enhancing patients' functional capacity and overall health status to enable them to withstand a forthcoming stressor like surgery. Our aim was to synthesise the evidence on the cost-effectiveness of prehabilitation for patients awaiting elective surgery compared with usual preoperative care.
METHODS
We searched PubMed, Embase, the CRD database, ClinicalTrials.gov, the WHO ICTRP and the dissertation databases OADT and DART. Studies comparing prehabilitation for patients with elective surgery to usual preoperative care were included if they reported cost outcomes. All types of economic evaluations (EEs) were included. The primary outcome of the review was cost-effectiveness based on cost-utility analyses (CUAs). The risk of bias of trial-based EEs was assessed with the Cochrane risk of bias 2 tool and the ROBINS-I tool and the credibility of model-based EEs with the ISPOR checklist. Methodological quality of full EEs was assessed using the CHEC checklist. The EEs' results were synthesised narratively using vote counting based on direction of effect.
RESULTS
We included 45 unique studies: 25 completed EEs and 20 ongoing studies. Of the completed EEs, 22 were trial-based and three model-based, corresponding to four CUAs, three cost-effectiveness analyses, two cost-benefit analyses, 12 cost-consequence analyses and four cost-minimization analyses. Three of the four trial-based CUAs (75%) found prehabilitation cost-effective, i.e. more effective and/or less costly than usual care. Overall, 16/25 (64.0%) EEs found prehabilitation cost-effective. When excluding studies of insufficient credibility/critical risk of bias, this number reduced to 14/23 (60.9%). In 8/25 (32.0%), cost-effectiveness was unclear, e.g. because prehabilitation was more effective and more costly, and in one EE prehabilitation was not cost-effective.
CONCLUSIONS
We found some evidence that prehabilitation for patients awaiting elective surgery is cost-effective compared to usual preoperative care. However, we suspect a relevant risk of publication bias, and most EEs were of high risk of bias and/or low methodological quality. Furthermore, there was relevant heterogeneity depending on the population, intervention and methods. Future EEs should be performed over a longer time horizon and apply a more comprehensive perspective.
TRIAL REGISTRATION
PROSPERO CRD42020182813.
Topics: Cost-Effectiveness Analysis; Preoperative Exercise; Humans; Elective Surgical Procedures
PubMed: 37468923
DOI: 10.1186/s12916-023-02977-6 -
European Journal of Anaesthesiology Oct 2023Pain after craniotomy can be intense and its management is often suboptimal.
BACKGROUND
Pain after craniotomy can be intense and its management is often suboptimal.
OBJECTIVES
We aimed to evaluate the available literature and develop recommendations for optimal pain management after craniotomy.
DESIGN
A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken.
DATA SOURCES
Randomised controlled trials and systematic reviews published in English from 1 January 2010 to 30 June 2021 assessing pain after craniotomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases.
ELIGIBILITY CRITERIA
Each randomised controlled trial (RCT) and systematic review was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and NSAIDs, and current clinical relevance.
RESULTS
Out of 126 eligible studies identified, 53 RCTs and seven systematic review or meta-analyses met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, NSAIDs, intravenous dexmedetomidine infusion, regional analgesia techniques, including incision-site infiltration, scalp nerve block and acupuncture. Limited evidence was found for flupirtine, intra-operative magnesium sulphate infusion, intra-operative lidocaine infusion, infiltration adjuvants (hyaluronidase, dexamethasone and α-adrenergic agonist added to local anaesthetic solution). No evidence was found for metamizole, postoperative subcutaneous sumatriptan, pre-operative oral vitamin D, bilateral maxillary block or superficial cervical plexus block.
CONCLUSIONS
The analgesic regimen for craniotomy should include paracetamol, NSAIDs, intravenous dexmedetomidine infusion and a regional analgesic technique (either incision-site infiltration or scalp nerve block), with opioids as rescue analgesics. Further RCTs are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.
Topics: Humans; Pain Management; Dexmedetomidine; Acetaminophen; Analgesics; Pain, Postoperative; Craniotomy; Anti-Inflammatory Agents, Non-Steroidal
PubMed: 37417808
DOI: 10.1097/EJA.0000000000001877 -
PloS One 2023Prehabilitation interventions are being delivered across surgical specialities to improve health risk behaviours leading to better surgical outcomes and potentially... (Meta-Analysis)
Meta-Analysis
The effect of preoperative behaviour change interventions on pre- and post-surgery health behaviours, health outcomes, and health inequalities in adults: A systematic review and meta-analyses.
BACKGROUND
Prehabilitation interventions are being delivered across surgical specialities to improve health risk behaviours leading to better surgical outcomes and potentially reduce length of hospital stay. Most previous research has focused on specific surgery specialities and has not considered the impact of interventions on health inequalities, nor whether prehabilitation improves health behaviour risk profiles beyond surgery. The aim of this review was to examine behavioural Prehabilitation interventions across surgeries to inform policy makers and commissioners of the best available evidence.
METHODS AND FINDINGS
A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted to determine the effect of behavioural prehabilitation interventions targeting at least one of: smoking behaviour, alcohol use, physical activity, dietary intake (including weight loss interventions) on pre- and post-surgery health behaviours, health outcomes, and health inequalities. The comparator was usual care or no treatment. MEDLINE, PubMed, PsychINFO, CINAHL, Web of Science, Google Scholar, Clinical trials and Embase databases were searched from inception to May 2021, and the MEDLINE search was updated twice, most recently in March 2023. Two reviewers independently identified eligible studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tool. Outcomes were length of stay, six-minute walk test, behaviours (smoking, diet, physical activity, weight change, and alcohol), and quality of life. Sixty-seven trials were included; 49 interventions targeted a single behaviour and 18 targeted multiple behaviours. No trials examined effects by equality measures. Length of stay in the intervention group was 1.5 days shorter than the comparator (n = 9 trials, 95% CI -2.6 to -0.4, p = 0.01, I2 83%), although in sensitivity analysis prehabilitation had the most impact in lung cancer patients (-3.5 days). Pre-surgery, there was a mean difference of 31.8 m in the six-minute walk test favouring the prehabilitation group (n = 19 trials, 95% CI 21.2 to 42.4m, I2 55%, P <0.001) and this was sustained to 4-weeks post-surgery (n = 9 trials, mean difference = 34.4m (95%CI 12.8 to 56.0, I2 72%, P = 0.002)). Smoking cessation was greater in the prehabilitation group before surgery (RR 2.9, 95% CI 1.7 to 4.8, I2 84%), and this was sustained at 12 months post-surgery (RR 1.74 (95% CI 1.20 to 2.55, I2 43%, Tau2 0.09, p = 0.004)There was no difference in pre-surgery quality of life (n = 12 trials) or BMI (n = 4 trials).
CONCLUSIONS
Behavioural prehabilitation interventions reduced length of stay by 1.5 days, although in sensitivity analysis the difference was only found for Prehabilitation interventions for lung cancer. Prehabilitation can improve functional capacity and smoking outcomes just before surgery. That improvements in smoking outcomes were sustained at 12-months post-surgery suggests that the surgical encounter holds promise as a teachable moment for longer-term behavioural change. Given the paucity of data on the effects on other behavioural risk factors, more research grounded in behavioural science and with longer-term follow-up is needed to further investigate this potential.
Topics: Adult; Humans; Exercise; Diet; Risk Factors; Smoking Cessation; Lung Neoplasms
PubMed: 37406002
DOI: 10.1371/journal.pone.0286757 -
BMJ Surgery, Interventions, & Health... 2023Perioperative nutrition aims to replenish nutritional stores before surgery and reduce postoperative complications. 'Immunonutrition' (including omega-3 fatty acids) may...
OBJECTIVES
Perioperative nutrition aims to replenish nutritional stores before surgery and reduce postoperative complications. 'Immunonutrition' (including omega-3 fatty acids) may modulate the immune system and attenuate the postoperative inflammatory response. Hitherto, immunonutrition has overwhelmingly been administered in the postoperative period-however, this may be too late to provide benefit.
DESIGN
A systematic literature search using MEDLINE and EMBASE for randomized controlled trials (RCTs).
SETTING
Perioperative major gastrointestinal surgery.
PARTICIPANTS
Patients undergoing major gastrointestinal surgery.
INTERVENTIONS
Omega-3 fatty acid supplementation commenced in the preoperative period, with or without continuation into postoperative period.
MAIN OUTCOME MEASURES
The effect of preoperative omega-3 fatty acids on inflammatory response and clinical outcomes.
RESULTS
833 studies were identified. After applying inclusion and exclusion criteria, 12 RCTs, involving 1456 randomized patients, were included. Ten articles exclusively enrolled patients with cancer. Seven studies used a combination of EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) as the intervention and five studies used EPA alone. Eight out of 12 studies continued preoperative nutritional support into the postoperative period.Of the nine studies reporting mortality, no difference was seen. Duration of hospitalisation ranged from 4.5 to 18 days with intervention and 3.5 to 23.5 days with control. Omega-3 fatty acids had no effect on postoperative C-reactive protein and the effect on cytokines (including tumor necrosis factor-α, interleukin (IL)-6 and IL-10) was inconsistent. Ten of the 12 studies had low risk of bias, with one study having moderate bias from allocation and blinding.
CONCLUSIONS
There is insufficient evidence to support routine preoperative omega-3 fatty acid supplementation for major gastrointestinal surgery, even when this is continued after surgery.
PROSPERO REGISTRATION NUMBER
CRD42018108333.
PubMed: 37397953
DOI: 10.1136/bmjsit-2022-000172