Perioperative epidural analgesia in children undergoing major abdominal tumor surgery — a single center experience

Purpose

The purpose of this study was to assess the use of continuous epidural analgesia in pediatric patients undergoing major abdominal tumor surgery.

Methods

Children undergoing major abdominal tumor surgery at our institution between 2008 and 2012 (n = 40) received continuous epidural analgesia via an epidural catheter. Surgical trauma scores, pain scores, and clinical data of the children were compared to a pair-matched historical control group operated on between 2002 and 2007 without epidural analgesia.

Results

Pain levels in the study group on day 1 and 3 after surgery were lower compared to the control group. The differences did, however, not reach statistical significance (p = 0.15 and 0.09). Children in the study group received significantly fewer additional doses of piritramide or morphine (45% versus 82%, p < 0.001). Despite significantly higher surgical trauma scores in the study group (p = 0.018), there were no statistical differences regarding clinical parameters, such as mechanical ventilation time, time on intensive care unit, and total hospital stay. There were no catheter-related complications.

Conclusions

Continuous epidural analgesia is beneficial for children undergoing complex abdominal tumor surgery with regard to pain levels, postoperative recovery, and general clinical course. Expertise of the managing team, a careful patient selection, and a continuous quality assessment are essential for success.     

Systematic Review and Meta-Analysis of Robotic-Assisted versus Conventional Laparoscopic Pyeloplasty for Patients with Ureteropelvic Junction Obstruction: Effect on Operative Time,Length of Hospital Stay,Postoperative Complications,and Success Rate

Background

Although robotic-assisted procedures may theoretically be more advantageous than conventional laparoscopic ones, few studies have shown clear superiority of robotic-assisted laparoscopic pyeloplasty (RAP) over conventional laparoscopic pyeloplasty (CLP) for ureteropelvic junction obstruction (UPJO).

Objective

To undertake a systematic review and meta-analysis to evaluate the effect of RAP versus CLP for patients with UPJO, focusing on operative time, length of hospital stay, postoperative complications, and success rate.

Design, setting, and participants

We searched four electronic bibliographic databases, including the related articles PubMed feature, reference lists from articles, and program abstracts from scientific meetings. Consequently, 58 citations were identified. Two individuals independently screened the titles and abstracts of each citation to select the articles (90% agreement).

Intervention

Studies that compared RAP with CLP for treatment of UPJO were included. Case series on RAP or CLP were excluded because of large heterogeneity.

Measurements

We utilized weighted mean difference (WMD) to measure operative time and length of hospital stay and odds ratio (OR) and risk difference (RD) to measure complication and success rates. These ORs were pooled using a random effects model and were tested for heterogeneity.

Results

We identified eight publications that strictly met our eligibility criteria. Meta-analysis of extractable data showed that RAP was associated with a 10-min operative time reduction (WMD: −10.4 min; 95% CI: −24.6–3; p = 0.15) and significantly shorter hospital stay compared with CLP (WMD: −0.5 d; 95% CI: −0.6–−0.4; p < 0.01). There were no differences between the approaches with regard to rates of complication (OR: 0.7; 95% CI: 0.3–1.6; p = 0.40) and success (OR: 1.3; 95% CI: 0.5–3.5; p = 0.62).

Conclusions

RAP and CLP appear to be equivalent with regard to postoperative urinary leaks, hospital readmissions, success rates, and operative time.     

Robotic Versus Laparoscopic Adrenalectomy: A Systematic Review and Meta-analysis

Context

Over the last decade, robot-assisted adrenalectomy has been included in the surgical armamentarium for the management of adrenal masses.

Objective

To critically analyze the available evidence of studies comparing laparoscopic and robotic adrenalectomy.

Evidence acquisition

A systematic literature review was performed in August 2013 using PubMed, Scopus, and Web of Science electronic search engines. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria.

Evidence synthesis

Nine studies were selected for the analysis including 600 patients who underwent minimally invasive adrenalectomy (277 robot assisted and 323 laparoscopic). Only one of the studies was a randomized clinical trial (RCT) but of low quality according to the Jadad scale. However, the methodological quality of included nonrandomized studies was relatively high. Body mass index was higher for the laparoscopic group (weighted mean difference [WMD]: −2.37; 95% confidence interval [CI], − 3.01 to −1.74; p < 0.00001). A transperitoneal approach was mostly used for both techniques (72.5% of robotic cases and 75.5% of laparoscopic cases; p = 0.27). There was no significant difference between the two groups in terms of conversion rate (odds ratio [OR]: 0.82; 95% CI, 0.39–1.75; p = 0.61) and operative time (WMD: 5.88; 95% CI, −6.02 to 17.79; p = 0.33). There was a significantly longer hospital stay in the conventional laparoscopic group (WMD: −0.43; 95% CI, −0.56 to −0.30; p < 0.00001), as well as a higher estimated blood loss (WMD: −18.21; 95% CI, −29.11 to −7.32; p = 0.001). There was also no statistically significant difference in terms of postoperative complication rate (OR: 0.04; 95% CI, −0.07 to −0.00; p = 0.05) between groups. Most of the postoperative complications were minor (80% for the robotic group and 68% for the conventional laparoscopic group). Limitations of the present analysis are the limited sample size and including only one low-quality RCT.

Conclusions

Robot-assisted adrenalectomy can be performed safely and effectively with operative time and conversion rates similar to laparoscopic adrenalectomy. In addition, it can provide potential advantages of a shorter hospital stay, less blood loss, and lower occurrence of postoperative complications. These findings seem to support the use of robotics for the minimally invasive surgical management of adrenal masses.     

Anesthesia and postoperative analgesia after percutaneous hallux valgus repair in ambulatory patients

Background

Postoperative pain is often severe after hallux valgus repair. Sciatic nerve blocks with long-acting local anesthetics have been recommended for surgical anesthesia and postoperative analgesia. However, a novel percutaneous approach may require less analgesia and make the procedure suitable for ambulatory care. We thus tested the hypothesis that mid-foot block and sciatic nerve blocks provide comparable surgical anesthesia and postoperative analgesia, but that patients ambulate independently sooner after mid-foot block.

Study design

Prospective, randomized study.

Methods

Forty patients scheduled for ambulatory percutaneous hallux valgus repair were randomly assigned to two anesthesia and analgesia blocks: foot infiltration achieved by a mild foot block, or sciatic nerve block (30 mL of 7.5% ropivacaine for each block). Surgery was performed without sedation or additional analgesia. Both groups were given oral paracetamol/codeine and ketoprofene systematically; tramadol was added if necessary. Walking ability and pain scores were assessed for 48 postoperative hours.

Results

Demographic and morphometric characteristics, and duration of surgery were similar in each group. Pain scores were comparable and low in each group at rest and while walking. The time to ambulation without assistance was significantly less for patients in the infiltration group (3.8 ± 1.4 hours) than patients in the sciatic group (19.2 ± 9.5 hours; P < 0.0001).

Conclusion

After percutaneous hallux valgus repair, mid-foot block and sciatic nerve block provided comparable postoperative analgesia. However, mid-foot block seems preferable since the time to ambulation without assistance is much reduced.     

Major abdominal surgery for cancer: Does epidural analgesia have a long-term effect on recurrence-free and overall survival?

Background

Retrospective studies have suggested that regional analgesia combined with general anaesthesia could decrease cancer recurrence. The purpose of this study was to assess the influence of regional analgesia on recurrence-free (RFS) and overall survival in patients undergoing major intra-abdominal surgery for cancer.

Method

Patients previously included in a prospective randomized study comparing two postoperative techniques of analgesia were retrospectively studied. The EP group received general anaesthesia with bupivacaine thoracic epidural analgesia and the SC group received general anaesthesia with fentanyl followed by continuous subcutaneous morphine.

Results

One hundred and thirty-two patients were analyzed (63 and 69 in SC and EP group, respectively) with a 17-year-median follow-up. After 5 years, RFS was 43% [95% CI: 32%–55%] in EP group and 24% [95% CI: 15%–36%] in SC group, but the difference did not reach statistical significance for RFS nor for overall survival (P = 0.10 and 0.16 respectively). Using multivariable analysis over the whole follow-up period, the type of analgesia was not a statistically significant predictive factor for RFS (EP/SC, HR = 1.3 [95% CI: 0.8–2.0%]). The anaesthesia effect changed moderately over the follow-up and HR for overall survival (EP/SC) reached statistical significance after 5, 6 and 8 years.

Conclusion

Despite a trend in favour of the epidural, this retrospective review of patients included in a previous randomized study failed to demonstrate a statistically significant association between the perioperative analgesia and RFS after abdominal surgery for cancer. The duration of follow-up may have an impact on the analgesia effect on survival.     

Comparaison prospective et randomisée de la morphine nébulisée versus la péridurale thoracique dans la prise en charge de la douleur des traumatisés thoraciques

Introduction

Successful management of pain reduces morbidity and improves patient satisfaction of patient after a chest trauma. The purpose of the study was to evaluate the efficacy of the respiratory administration of nebulized morphine in such patients.

Patients and methods

Patients were included in this prospective and randomized study patients to receive either nebulized morphine in group M or a mixture of bupivacaine-fentanyl by epidural route. In group M, patients received nebulized morphine every 30 minutes until the second hour then every 4 hours during 48 hours. In the thoracic epidural analgesia group (group P) they received a mixture of 0.125% bupivacaine and 0.115% of fentanyl continuously infused at the rate of 7 ml/h during 48 hours. The main criterion of judgment was the analgesic effects of analgesic regimen with EVA < 4. Sedation, haemodynamic and respiratory parameters were continuously recorded, as adverse side effects were they occurred. Statistical comparisons were performed with Chi², Fisher or Student t-test when appropriate (p < 0.05).

Results

Forty patients were randomized in two groups. Groups were not different regarding the demographic parameters. Analgesia was effective in both groups (NS). Sedation, hemodynamic and respiratory parameters were not different between groups. No side effect was noted in groups.

Conclusion

Nebulized morphine was an analgesic technique as effective as epidural bupivacaine-fentanyl in our series. This non-invasive route of administration of morphine appears to be useful to treat pain after a chest trauma.     

Low-dose ketamine with multimodal postcesarean delivery analgesia: a randomized controlled trial

Background

Ketamine at subanesthetic doses has analgesic properties that have been shown to reduce postoperative pain and morphine consumption. We hypothesized that intravenous ketamine 10 mg administered during spinal anesthesia for cesarean delivery, in addition to intrathecal morphine and intravenous ketorolac, would decrease the incidence of breakthrough pain and need for supplemental postoperative analgesia.

Methods

Using a randomized double-blind placebo-controlled design, healthy women scheduled for cesarean delivery receiving hyperbaric spinal bupivacaine, fentanyl and morphine were randomized to intravenous ketamine 10 mg or saline following delivery. Postoperative analgesia included scheduled ketorolac and acetaminophen/hydrocodone tablets as needed for breakthrough pain. The primary outcome was the incidence of breakthrough pain in the first 24 h. Secondary outcomes included the number of acetaminophen/hydrocodone tablets administered and numeric rating scale for pain (0-10).

Results

Group characteristics did not differ. There was no difference in the incidence of breakthrough pain (ketamine 75% VS. saline 74%, P = 0.86). There was no difference in 24-h or 72-h use of supplemental acetaminophen/hydrocodone tablets between groups. Pain scores in the first 24 h were similar, but lower in the ketamine compared to the saline group 2 weeks postpartum (difference −0.6, 95% CI −1.1 to −0.9).

Conclusions

We found no additional postoperative analgesic benefit of low-dose ketamine during cesarean delivery in patients who received intrathecal morphine and intravenous ketorolac. Subjects who received ketamine reported lower pain scores 2 weeks postpartum.     

Epidural analgesia in obstetrics: anaesthesiologists practice in Auvergne

Objective

To evaluate the practice of labour epidural analgesia in Auvergne.

Study design

Cross-sectional study by a mail survey.

Methods

An anonymous postal questionnaire was sent to all anaesthetists working in public or private hospital having a maternity unit.

Results

The response rate was 82%. Eighty-eight percent of the respondents practise epidural analgesia in obstetrics (EAO) for labour pain relief, but 49% of them did so only on call. Fifty percent of the respondents ask for platelets and fibrinogen beforehand and 41% accept a one month validity for these tests. One third uses a full aseptic method (surgical hand washing, cap and face mask, sterile gloves and gown, double disinfection of patient's back). Nearly all respondents practice skin anaesthesia, 67% use saline solution for identification of the epidural space, 58% insert the catheter 4 cm into the epidural space and 25% use a lidocaine–epinephrine epidural test dose. The analgesic solution is mostly based on ropivacaine (83%) associated with sufentanil (96%); patient controlled epidural analgesia rate is used by 58% of anaesthetists whereas 37% of them never use epidural clonidine and 52% never practice combined spinal epidural (CSE) analgesia during labour.

Conclusion

EAO is mainly practiced on call. There are too many laboratory tests ordered before EAO. Technique used to insert epidural catheter is partly uniform and ropivacaine with sufentanil is the analgesic solution most often used. CSE for labour analgesia is still not often used.     

Risk factors for persistent pain after urological surgery

Objective

Ten to 50% of patients with post-surgical pain develop chronic pain depending on the type of surgery. The objective of this study was to assess the incidence of persistent post-surgical pain (PPSP) and to identify risk factors following urology surgery.

Design

Retrospective observational study.

Patients

Two hundred and twenty-eight patients scheduled for urology surgery. Reasons for non-inclusions: patients who underwent a procedure not defined as being associated with PPSP.

Methods

Surgical urologic procedures potentially associated with PPSP were defined. All patients who had one of these procedures during the study period received a questionnaire by mail at least 3 months after the surgery. The files of these patients were retrospectively studied.

Results

Eight percent of the patients had preoperative pain. PPSP, assessed approximately 6 months after the surgery, was reported by 24% of the patients. Twenty-five (36%) of them reported neuropathic pain. Patients with PPSP had significantly more preoperative pain and an increased postoperative morphine consumption. Postoperative NSAID administration led to less persistent pain. Multivariate logistic regression analysis identified two independent risk factors of developing persistent pain: preoperative pain (OR = 21.6, 95% CI 6.7–69.5, P < 0.0001), morphine consumption 48 hours after surgery higher than 6 mg (OR = 2.3, 95% CI 1.2–4.3, P = 0.0118).

Conclusion

These findings confirm the role of preoperative pain and morphine consumption in the genesis of PPSP and call for establishing clinical perioperative pathways tailored to the patient.     

Postoperative pain management in pediatric patients undergoing minimally invasive repair of pectus excavatum: The role of intercostal block

Purpose

There are no published data regarding value of intercostal block following pectus excavatum repair. Our aim was to evaluate the efficacy of intercostal block in children following minimally invasive repair of pectus excavatum (MIRPE).

Methods

Forty-five patients given patient-controlled analgesia (PCA) with morphine postoperatively were studied. Twenty-six patients were given bilateral intercostal blocks after induction of anesthesia (PCA-IB group), and nineteen patients were retrospective controls without regional blockade (PCA group). All patients were followed up 24 h postoperatively.

Results

A loading dose of morphine (0,1 ± 0,49 mg/kg) before starting PCA was used in seventeen patients in PCA group vs. no patient in PCA-IB group. Cumulative used morphine doses were lower up to 12 h after surgery in PCA-IB group (0,29 ± 0,08 μg/kg) than in the PCA group (0,46 ± 0,18 μg/kg), p < 0,01. There were no differences in pain scores, oxygen saturation values, sedation scores, and the incidence of pulmonary adverse events between the two groups. There was a tendency towards less morphine-related adverse effects in PCA-IB group compared to PCA group (p < 0,05). No complications related to the intercostal blocks were observed.

Conclusion

Bilateral intercostal blocks following MIRPE are safe and easy to perform and can diminish postoperative opioid requirement. Double-blind randomized study is required to confirm the potential to diminish opioid related side effects.     

The long term physical consequences of gastroschisis

Purpose

To determine the progress, physical and metabolic outcomes of gastroschisis survivors.

Methods

Fifty children born with gastroschisis were assessed with a health questionnaire, physical assessment, bone density and nutritional blood parameters at a median age of 9 years (range 5–17).

Results

After initial abdominal closure, 27/50 (54%) required additional surgical interventions. Ten (20%) children had complex gastroschisis (CG). Abdominal pain was common: weekly in 41%; and requiring hospitalization in 30%. The weight, length and head circumference z-scores improved by a median 0.88 (p = 0.001), 0.56 (p = 0.006) and 0.74 (p = 0.018) of a standard deviation (SD) respectively from birth; 24% were overweight or obese at follow up. However, those with CG had significantly lower median weight z-scores (− 0.43 v 0.49, p = 0.0004) and body mass index (BMI) (− 0.48 v 0.42, p = 0.001) at follow up compared to children with simple gastroschisis. Cholesterol levels were elevated in 24% of children. Bone mineral density was reassuring. There were 15 instances of low blood vitamin and mineral levels.

Conclusions

Although gastroschisis survival levels are high, many children have significant ongoing morbidity. Children with simple gastroschisis showed significant catch up growth and a quarter had become overweight.     

Outcome of CDH infants following fetoscopic tracheal occlusion — influence of premature delivery

Purpose

To evaluate the mortality and morbidity of infants with congenital diaphragmatic hernia who had undergone fetal endoscopic tracheal occlusion (FETO) and whether this was influenced by premature birth.

Methods

The gestational age at delivery, lung–head ratio (LHR) pre and post FETO, neonatal outcomes, and respiratory, gastro-intestinal, neurological, surgical, and musculoskeletal problems at follow up of consecutive infants who had undergone FETO were determined. Elective reversal of FETO was planned at 34 weeks of gestation.

Results

The survival rate of the 61 FETO infants was 48%, with 84% delivered prematurely. Thirty-one delivered < 35 weeks of gestation. Their survival rate was 18%. Twenty-three of 24 infants who had emergency balloon removal were born < 35 weeks of gestation. Survival was related to gestational age at delivery (OR 0.55, 95% CI 0.420, 0.77, p < 0.001) and the duration of FETO (OR 0.73, 95% CI 0.59, 0.91, p < 0.005). Infants born prior to 35 weeks of gestation compared to those born at ≥ 35 weeks required a longer duration of ventilation (median 45 days versus 12 days, p < 0.001), and a greater proportion had surgery for gastro-oesophageal reflux (50% versus 9%, p = 0.011).

Conclusion

These results emphasize the need to reduce premature delivery following FETO.     

Enquête de pratique sur l’analgésie péridurale en dehors de l’obstétrique

Objectives

To describe the current use of epidural anesthesia (EA) apart from obstetrics, and to explain the reasons of its low utilization.

Study design

Observational study.

Methods

A survey of practice with a self-questionnaire was sent by e-mail and available on Internet. Answers were compared between groups doing or not an epidural analgesia with exact Fisher tests (P < 0.05 statistically significant).

Results

Among the 176 anesthesiologists who answered to the questionnaire, only 21.4% never used epidural analgesia. The main reasons were alternatives therapeutics such as PCA with opioids or TAP block (24/38 vs. 46/140). TAP block was the most common alternative used by more than 50% of anesthesiologists. Loss of competence (4/30 vs. 0/39) was rarely the reason to its low utilization. The low accessibility to specialized postoperative units was recognized in both groups as a limiting factor to do an epidural but not the fear of neurological complications. Those who never perform epidural analgesia were statistically more often physicians between 40 and 50 years (12/38 vs. 19/140). Heparin, aspirin and clopidogrel are no longer contraindications according to anesthesiologists less than 40 years old (50/68 vs. 31/68; 44/68 vs. 31/68; 37/68 vs. 23/68 respectively) but not for older.

Conclusions

Epidural analgesia is performed more often by younger anesthesiologists. This survey suggests the need of specific postoperative area to allow anesthesiologist to perform and supervise safely this technique. Recommendations of the French society of Anesthesiologists are also poorly applied.     

An effective dose of ketamine for eliminating pain during injection of propofol: A dose response study

Background and purpose

Ketamine can completely eliminate pain associated with propofol injection. However, the effective dose of ketamine to eliminate propofol injection pain has not been determined. The purpose of this study was to determine the effective dose of ketamine needed to eliminate pain in 50% and 95% of patients (ED50 and ED95, respectively) during propofol injections.

Methods

This study was conducted in a double-blinded fashion and included 50 patients scheduled for elective gynecological laparoscopy under general anesthesia. The initial dose of ketamine used in the first patient was 0.25 mg/kg. The dosing modifications were in increments or decrements of 0.025 mg/kg. Ketamine was administered 15 seconds before injecting propofol (2.5 mg/kg), which was injected at a rate of 1 mL/s. Patients were asked to rate their pain during propofol injection every 5 seconds using a 0–3 pain scale. The highest pain score was recorded. The ED50, ED95 and 95% confidence intervals (CI) were determined by probit analyses.

Results

The dose of ketamine ranged from 0.175 to 0.275 mg/kg. The ED50 and ED95 of ketamine for eliminating pain during propofol injection were 0.227 mg/kg and 0.283 mg/kg, respectively (95%CI: 0.211–0.243 mg/kg and 0.26–0.364 mg/kg, respectively).

Conclusion

Ketamine at an approximate dose of 0.3 mg/kg was effective in eliminating pain during propofol injection.     

Analgesia in the management of paediatric and adolescent trauma during the resuscitative phase: The role of the pediatric trauma centre

Background

The objective of this study was to evaluate the use of analgesia in the resuscitative phase of severely injured children and adolescents.

Methods

A retrospective cohort of paediatric (age < 18 years), severely injured (ISS ≥ 12) patients were identified from the London Health Sciences Centre's Trauma Registry from 2007 to 2010. Variables were compared between Analgesia and Non-analgesia groups with Pearson Chi-square and Mann–Whitney U tests. Resuscitative analgesia use was assessed through multivariable logistic regression controlling for age, gender, mechanism, arrival and Trauma Team Activation (TTA).

Results

Analgesia was used in 32% of cases. Univariate analysis did not reveal any differences in gender, age, injury type, injury profile and arrival patterns. Significant differences were found with analgesia used more frequently in patients injured in a motor vehicle collision (58% vs. 42%, p = 0.026) and having parents in the resuscitation room (17% vs. 6%, p = 0.01). Analgesia patients were more injured (median ISS 22 vs. 17, p = 0.027) and had 2.25 times more TTA (39% vs. 17%). Logistic regression revealed patients arriving directly to a trauma centre had a higher incidence of receiving analgesia (OR 2.01, 95% CI: 1.03–3.93), as did TTA (OR 2.18, 95% CI: 1.01–4.73) and having parents in resuscitation room (3.56, 95% CI: 1.23–10.33). Narcotics were most commonly used (85%), followed by benzodiazepines (16%), with 66% given during the primary survey.

Conclusion

Use of analgesia is important in the acute management of paediatric trauma. Direct presentation to a level I trauma centre, TTA and the presence of parents lead to higher appropriate use of analgesia in paediatric trauma resuscitation.     

Laparoendoscopic Single-Site Nephrectomy Compared with Conventional Laparoscopic Nephrectomy: A Systematic Review and Meta-analysis of Comparative Studies

Context

Laparoendoscopic single-site (LESS) surgery has increasingly been used to perform radical, partial, simple, or donor nephrectomy to reduce the morbidity and scarring associated with surgical intervention. Studies comparing LESS nephrectomy (LESS-N) and conventional laparoscopic nephrectomy (CL-N) have reported conflicting results.

Objective

To assess the current evidence regarding the efficiency, safety, and potential advantages of LESS-N compared with CL-N.

Evidence acquisition

We comprehensively searched PubMed, Embase, and the Cochrane Library and performed a systematic review and cumulative meta-analysis of all randomized controlled trials (RCTs) and retrospective comparative studies assessing the two techniques.

Evidence synthesis

Two RCTs and 25 retrospective studies including a total of 1094 cases were identified. Although LESS-N was associated with a longer operative time (weighted mean difference [WMD]: 9.87 min; 95% confidence interval [CI], 3.37–16.38; p = 0.003) and a higher conversion rate (6% compared with 0.3%; odds ratio: 4.83; 95% CI, 1.87–12.45; p = 0.001), patients in this group might benefit from less postoperative pain (WMD: −0.48; 95% CI, −0.95 to −0.02; p = 0.04), lower analgesic requirement (WMD: −4.78 mg; 95% CI, −8.59 to −0.97; p = 0.01), shorter hospital stay (WMD: −0.32 d; 95% CI, −0.55 to −0.09; p = 0.007), shorter recovery time (WMD: −5.08 d; 95% CI, −8.49 to −1.68; p = 0.003), and better cosmetic outcome (WMD: 1.07; 95% CI, 0.67–1.48; p < 0.00001). Perioperative complications, estimated blood loss, warm ischemia time, and postoperative serum creatinine levels of graft recipients did not differ significantly between techniques.

Conclusions

LESS-N offers a safe and efficient alternative to CL-N with less pain, shorter recovery time, and better cosmetic outcome. Given the inherent limitations of the included studies, future well-designed RCTs are awaited to confirm and update the findings of this analysis.     

Primary malignant pancreatic neoplasms in children and adolescents: A 20 year experience

Background

Malignant pancreatic neoplasms in children and adolescents are rare. The clinical presentation, pathologic characteristics, management, and outcomes at two institutions are discussed.

Methods

We retrospectively reviewed all pediatric patients (age < = 18 years) treated for malignant pancreatic neoplasms at two institutions between 1991 and 2011.

Results

Thirty-one patients were identified with median age of 14.7 years (4–18 years). The most common histology was solid pseudopapillary tumor (SPT) (n = 22, 71%) followed by neuroendocrine tumors (n = 4, 13%), pancreatoblastoma (n = 4, 13%), and one unclassified spindle cell neoplasm (3%). Most patients presented with abdominal pain (n = 22, 71%). Complications included pancreatic leak, pseudocyst formation, pancreatitis, pancreatic insufficiency, and small bowel obstruction. The overall 1- and 5-year survival was 96% (95% CI 74%–99%) and 78% (95% CI 43%–93%). Median follow-up among patients alive at the end of follow-up was 20 months (< 1 month–16.2 years). Patients with SPT had better overall survival compared to patients with neuroendocrine tumors or pancreatoblastomas (Log-rank; p = 0.0143).

Conclusion

The majority of pediatric and adolescent patients present with SPTs which are usually resectable and associated with an excellent prognosis. Other histologic subtypes more often present with distant metastases and portend a worse prognosis.     

Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials

Purpose

A consensus group recently proposed epidural analgesia as the optimal analgesic modality for patients with multiple traumatic rib fractures. However, its beneficial effects are not consistently recognized in the literature. We performed a systematic review and a meta-analysis of randomized controlled trials (RCT) of epidural analgesia in adult patients with traumatic rib fractures.

Methods

A systematic search strategy was applied to MEDLINE, EMBASE, the Cochrane Library and to the annual meeting of relevant societies (up to July 2008). All randomized controlled trials comparing epidural analgesia with other analgesic modalities in adult patients with traumatic rib fractures were included. Primary outcomes were mortality, ICU length of stay (LOS), hospital LOS and duration of mechanical ventilation.

Results

Eight studies (232 patients) met eligibility criteria. Epidural analgesia did not significantly affect mortality (odds ratio [OR] 1.6, 95% CI, 0.3, 9.3, 3 studies, n = 89), ICU LOS (weighted mean difference [WMD] ?3.7 days, 95% CI, ?11.4, 4.0, 4 studies, n = 135), hospital LOS (WMD ?6.7, 95% CI, ?19.8, 6.4, 4 studies, n = 140) or duration of mechanical ventilation (WMD ?7.5, 95% CI, ?16.3, 1.2, 3 studies, n = 101). Duration of mechanical ventilation was decreased when only studies using thoracic epidural analgesia with local anesthetics were evaluated (WMD ?4.2, 95% CI, ?5.5, ?2.9, 2 studies, n = 73). However, hypotension was significantly associated with the use of thoracic epidural analgesia with local anesthetics (OR 13.76, 95% CI, 2.89, 65.51, 3 studies, n = 99).

Conclusions

No significant benefit of epidural analgesia on mortality, ICU and hospital LOS was observed compared to other analgesic modalities in adult patients with traumatic rib fractures. However, there may be a benefit on the duration of mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics. Further research is required to evaluate the benefits and harms of epidural analgesia in this population before being considered as a standard of care therapy.     

Single-incision mini-slings versus standard midurethral slings in surgical management of female stress urinary incontinence: a meta-analysis of effectiveness and complications

Context

Single-incision mini-slings (SIMS) have been introduced for the treatment of female stress urinary incontinence (SUI); however, concerns have been raised regarding their efficacy. No systematic reviews or meta-analyses have previously assessed these relatively new procedures.

Objective

To assess the current evidence of effectiveness and safety of SIMS compared with standard midurethral slings (SMUS) (retropubic and transobturator tension-free vaginal tapes) in the management of female SUI.

Evidence acquisition

We conducted a literature search from 1996 to January 2011. Meta-analysis of all randomised controlled trials (RCTs) comparing SIMS versus SMUS was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data were analysed using Rev-Man 5. Primary outcomes were patient-reported and objective cure rates. Secondary outcomes included perioperative complications, quality of life (QoL) changes, and costs to health services.

Evidence synthesis

A total of 758 women in nine RCTs with a mean follow-up of 9.5 mo were included. The mean age (52.3 vs 52.1 yr), body mass index (27.4 vs 27.7), and parity (2.4 and 2.4) were comparable for both groups. SIMS were associated with significantly lower patient-reported and objective cure rates at 6-12 mo compared with SMUS (risk ratio [RR]: 0.83; 95% confidence interval [CI], 0.70-0.99, and RR: 0.85; 95% CI, 0.74-0.97, respectively). SIMS were associated with significantly shorter operative time (weighed mean difference [WMD]: 8.67 min; 95% CI, 17.32 to −0.02), lower day 1 pain scores (WMD: 1.74; 95% CI, −2.58 to −0.09), and less postoperative groin pain (RR: 0.18; 95% CI, 0.04-0.72). Repeat continence surgery (RR: 6.72; 95% CI, 2.39-18.89) and de novo urgency incontinence (RR: 2.08; 95% CI, 1.01-4.28) were significantly higher in the SIMS group. There was no significant difference in the QoL scores between the groups (WMD: 33.46; 95% CI, −20.62 to 87.55). No studies compared cost to health services.

Conclusions

SIMS are associated with inferior patient-reported and objective cure rates on the short-term follow-up, as well as higher reoperation rates for SUI when compared with SMUS.