Aim Reduced opioid use in the immediate postoperative period is associated with decreased complications. This study aimed to determine the effect of transversus abdominis plane (TAP) block on ...morphine requirements 24 h after abdominal surgery. Secondary outcomes included the effect of TAP block on morphine use 48 h after surgery, incidence of postoperative nausea and vomiting (PONV) and impact on reported pain scores (visual analogue scale).
Method A systematic review of the literature was conducted for randomised controlled trials (RCTs) evaluating the effects of TAP block in adults undergoing abdominal surgery. For continuous data, weighted mean differences (WMD) were formulated; for dichotomous data, odds ratios (OR) were calculated. Results were produced with a random effects model with 95% confidence intervals (CI).
Results Nine studies, including published and unpublished data, containing a total of 413 patients were included. Of these 205 received a TAP block and 208 a placebo. Cumulative morphine utilization was statistically significantly reduced at 24 h. WMD = 23.71 mg (38.66–8.76); P = 0.002 and 48 h WMD = 38.08 mg (18.97–57.19); P < 0.0001 in patients who received a TAP block and the incidence of PONV was significantly reduced OR = 0.41(0.22–0.74); P = 0.003. There was a nonsignificant reduction in the visual analogue scales of postoperative pain WMD = 0.73 cm (1.84–0.38), P = 0.2. There were no reported adverse events following TAP block.
Conclusion Transversus abdominis plane block is safe, reduces postoperative morphine requirements, nausea and vomiting and possibly the severity of pain after abdominal surgery. It should be considered as part of a multimodal approach to anaesthesia and enhanced recovery in patients undergoing abdominal surgery.
Background
Local anaesthetic wound infiltration techniques reduce opiate requirements and pain scores. Wound catheters have been introduced to increase the duration of action of local anaesthetic by ...continuous infusion. The aim was to compare these infiltration techniques with the current standard of epidural analgesia.
Methods
A meta‐analysis of randomized clinical trials (RCTs) evaluating wound infiltration versus epidural analgesia in abdominal surgery was performed. The primary outcome was pain score at rest after 24 h on a numerical rating scale. Secondary outcomes were pain scores at rest at 48 h, and on movement at 24 and 48 h, with subgroup analysis according to incision type and administration regimen (continuous versus bolus), opiate requirements, nausea and vomiting, urinary retention, catheter‐related complications and treatment failure.
Results
Nine RCTs with a total of 505 patients were included. No differences in pain scores at rest 24 h after surgery were detected between epidural and wound infiltration. There were no significant differences in pain score at rest after 48 h, or on movement at 24 or 48 h after surgery. Epidural analgesia demonstrated a non‐significant a trend towards reduced pain scores on movement and reduced opiate requirements. There was a reduced incidence of urinary retention in the wound catheter group.
Conclusion
Within a heterogeneous group of RCTs, use of local anaesthetic wound infiltration was associated with pain scores comparable to those obtained with epidural analgesia. Further procedure‐specific RCTs including broader measures of recovery are recommended to compare the overall efficacy of epidural and wound infiltration analgesic techniques.
Similar effect on short‐term pain relief
MicroRNAs: new players in IBD Kalla, R; Ventham, N T; Kennedy, N A ...
Gut,
03/2015, Letnik:
64, Številka:
3
Journal Article
Recenzirano
Odprti dostop
MicroRNAs (miRNAs) are small non-coding RNAs, 18-23 nucleotides long, which act as post-transcriptional regulators of gene expression. miRNAs are strongly implicated in the pathogenesis of many ...common diseases, including IBDs. This review aims to outline the history, biogenesis and regulation of miRNAs. The role of miRNAs in the development and regulation of the innate and adaptive immune system is discussed, with a particular focus on mechanisms pertinent to IBD and the potential translational applications.
Epigenetic alterations may provide important insights into gene-environment interaction in inflammatory bowel disease (IBD). Here we observe epigenome-wide DNA methylation differences in 240 ...newly-diagnosed IBD cases and 190 controls. These include 439 differentially methylated positions (DMPs) and 5 differentially methylated regions (DMRs), which we study in detail using whole genome bisulphite sequencing. We replicate the top DMP (RPS6KA2) and DMRs (VMP1, ITGB2 and TXK) in an independent cohort. Using paired genetic and epigenetic data, we delineate methylation quantitative trait loci; VMP1/microRNA-21 methylation associates with two polymorphisms in linkage disequilibrium with a known IBD susceptibility variant. Separated cell data shows that IBD-associated hypermethylation within the TXK promoter region negatively correlates with gene expression in whole-blood and CD8
T cells, but not other cell types. Thus, site-specific DNA methylation changes in IBD relate to underlying genotype and associate with cell-specific alteration in gene expression.
Background
Return of normal gastrointestinal (GI) function is a critical determinant of recovery after colorectal surgery. The aim of this meta-analysis was to evaluate whether perioperative ...intravenous (IV) lidocaine benefits return of gastrointestinal function after colorectal resection.
Methods
A comprehensive search of Ovid Medline, PubMed, Embase, Cochrane library, and clinicaltrials.org was performed on 1st July 2018. A manual search of reference lists was also performed. Inclusion criteria were as follows: randomized controlled trials (RCTs) of intravenous (IV) lidocaine administered perioperatively compared to placebo (0.9% saline infusion) as part of a multimodal perioperative analgesic regimen, human adults (> 16 years), and open or laparoscopic colorectal resectional surgery. Exclusion criteria: non-colorectal surgery, non-placebo comparator, children, non-general anaesthetic, and pharmacokinetic studies. The primary endpoint was time to first bowel movement. Secondary endpoints were time to first passage of flatus, time to toleration of diet, nausea and vomiting, ileus, pain scores, opioid analgesia consumption, and length of stay.
Results
One hundred and ninety one studies were screened, with 9 RCTs meeting inclusion criteria (405 patients, four laparoscopic and five open surgery studies). IV lidocaine reduced time to first bowel movement compared to placebo seven studies, 325 patients, mean weighted difference − 9.54 h, 95% CI 18.72–0.36,
p
= 0.04. Ileus, pain scores, and length of stay were reduced with IV lidocaine compared with placebo.
Conclusions
Perioperative IV lidocaine may improve recovery of gastrointestinal function after colorectal surgery. Large-scale effectiveness studies to measure effect size and evaluate optimum dose/duration are warranted.
Abstract
Background
MicroRNAs miRNAs are cell-specific small non-coding RNAs that can regulate gene expression and have been implicated in inflammatory bowel disease IBD pathogenesis. Here we define ...the cell-specific miRNA profiles and investigate its biomarker potential in IBD.
Methods
In a two-stage prospective multi-centre case control study, next generation sequencing was performed on a discovery cohort of immunomagnetically separated leukocytes from 32 patients (nine Crohn’s disease CD, 14 ulcerative colitis UC, eight healthy controls) and differentially expressed signals were validated in whole blood in 294 patients 97 UC, 98 CD, 98 non-IBD, 1 IBDU using quantitative PCR. Correlations were analysed with phenotype, including need for early treatment escalation as a marker of progressive disease using Cox proportional hazards.
Results
In stage 1, each leukocyte subset CD4+ and CD8+ T-cells and CD14+ monocytes was analysed in IBD and controls. Three specific miRNAs differentiated IBD from controls in CD4+ T-cells, including miR-1307-3p p = 0.01, miR-3615 p = 0.02 and miR-4792 p = 0.01. In the extension cohort, in stage 2, miR-1307-3p was able to predict disease progression in IBD (hazard ratio HR 1.98, interquartile range IQR: 1.20–3.27; logrank p = 1.80 × 10–3), in particular CD HR 2.81; IQR: 1.11–3.53, p = 6.50 × 10–4. Using blood-based multimarker miRNA models, the estimated chance of escalation in CD was 83% if two or more criteria were met and 90% for UC if three or more criteria are met.
Interpretation
We have identified and validated unique CD4+ T-cell miRNAs that are differentially regulated in IBD. These miRNAs may be able to predict treatment escalation and have the potential for clinical translation; further prospective evaluation is now indicated.
The optimal analgesic technique following open abdominal surgery within an enhanced recovery protocol remains controversial. Thoracic epidural is often recommended; however, its role is increasingly ...being challenged and alternative techniques are being suggested as suitable replacements.
To determine by meta-analysis whether epidurals are superior to alternative analgesic techniques following open abdominal surgery within an enhanced recovery setting in terms of postoperative morbidity and other markers of recovery.
A literature search was performed of EMBASE, Medline, PubMed, and the Cochrane databases from 1966 through May 2013.
All randomized clinical trials comparing epidurals with an alternative analgesic technique following open abdominal surgery within an enhanced recovery protocol were included.
All studies were assessed by 2 independent reviewers. Study quality was assessed using the Cochrane bias assessment tool and the Jadad and Chalmers modified bias risk assessment tools. Dichotomous data were analyzed by random or fixed-effects odds ratios. Qualitative analysis was performed where appropriate.
Seven trials with a total of 378 patients were identified. No significant difference in complication rate was detected between epidurals and alternative analgesic methods (odds ratio, 1.14; 95% CI, 0.49-2.64; P = .76). Subgroup analysis showed fewer complications in the patient-controlled analgesia group compared with epidural analgesia (odds ratio, 1.97; 95% CI, 1.10-3.53; P = .02). Following qualitative assessment, epidural analgesia was associated with faster return of gut function and reduced pain scores; however, no difference was observed in length of stay.
Epidurals may be associated with superior pain control but this does not translate into improved recovery or reduced morbidity when compared with alternative analgesic techniques when used within an enhanced recovery protocol.
Summary
Background
Scottish nationwide linkage data from 1998 to 2000 demonstrated high 3‐year mortality in patients hospitalised with ulcerative colitis (UC).
Aim
To compare 3‐year mortality, and ...factors related to mortality, in Scottish patients hospitalised with UC between 1998–2000 and 2007–2009.
MethodsThe Scottish Morbidity Records and linked datasets were used to assess 3‐year mortality, standardised mortality ratio (SMR) and multivariate analyses of factors associated with 3‐year mortality. The 3‐year mortality was determined after four admission types: surgery‐elective or emergency; medical‐elective or emergency. Age‐standardised mortality rates (ASR) were used to compare mortality rates between periods.
Results
Ulcerative colitis admissions increased from 10.6 in Period 1 to 11.6 per 100 000 population per year in Period 2 (P = 0.046). Crude and adjusted 3‐year mortality fell between time periods (crude 12.2% to 8.3%; adjusted OR 0.59, CI 0.42–0.81, P = 0.04). Adjusted 3‐year mortality following emergency medical admission (OR 0.58, CI 0.39–0.87, P = 0.003) and in patients >65 years (38.8% to 28.7%, P = 0.02) was lower in Period 2. The SMR in period 1 was 3.04 and 2.96 in Period 2. Directly age‐standardised mortality decreased from 373 (CI 309–437) to 264 (CI 212–316) per 10 000 person‐years. On multivariate analysis, increasing age (50–64 years OR 7.11 (CI 2.77–18.27, P < 0.05); 65–74 years OR 14.70 (CI 5.65–38.25 P < 0.05); >75 years OR 46.42 (CI 18.29–117.78, P < 0.001) and co‐morbidity (OR 3.02, CI 1.72–5.28, P < 0.001) were significantly associated with 3‐year mortality in Period 2.
Conclusions
Comparisons of crude and adjusted mortality rates suggest significant improvement in outcome over the last decade – however, mortality remains high, and older age and co‐morbidity are important predictors of outcome.
Reducing exogenously administered opioids in the post-operative period is associated with early return of bowel function and decreased post-operative complication rates. We evaluated the ...effectiveness of a surgeon-delivered open transversus abdominis plane (TAP) block as a method to reduce post-operative opioid requirements, sedation and inpatient stay.
The patient cohort was identified from those who had undergone a right hemicolectomy for colonic cancer. Patients received either an open TAP block and post-operative patient controlled anaesthesia (PCA) ( n =20) or were part of a control group who received subcutaneous local anaesthetic infiltration and PCA ( n =16).
PCA morphine use was reduced within the first 24 hours post-operatively in the TAP block group compared with controls (42.1mg vs 72.3mg, p =0.002). Sedation was also reduced significantly in the early post-operative period (p <0.04). There was a non-significant trend towards reduced length of stay in the intervention group (8.2 vs 8.73 days). There were no recorded complications attributable to the open TAP block.
Open TAP blocks are safe and reduce post-operative opioid requirements and sedation after right hemicolectomies. They should be considered as part of a multimodal enhanced recovery approach to patients undergoing abdominal surgery via a transverse incision.
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