Modified pectoral nerve block versus bi-level erector spinae plane block for postoperative analgesia after radical mastectomy surgery: a prospective, randomized, controlled trial

Background Regional anesthesia techniques constitute an important part of successful analgesia strategies in the perioperative care of patients undergoing breast surgery. The advent of ultrasound-guided regional anesthesia has led to the development of fascial plane blocks. The large array of blocks available for postoperative analgesia in breast surgery has increased the accessibility of regional anesthesia but has also created a dilemma of choice. This study compared the analgesic efficacy of the ultrasound-guided modified pectoral nerve (PECS) block and erector spinae plane block (ESPB) in patients undergoing radical mastectomy. Methods Seventy women were enrolled in this prospective, double-blind, randomized control trial. After exclusion, 67 female patients who underwent radical mastectomy were finally analyzed. Ultrasound-guided PECS blocks and ESPBs were performed with 30 ml 0.25% bupivacaine. Postoperative morphine and pain scores were compared between the groups. Results Postoperative total morphine consumption in the first 24 h was significantly higher in the PECS group (P < 0.001). The ESPB group exhibited significantly reduced morphine consumption at all postoperative time points. Numeric rating scale scores were lower in the ESPB group at 6, 12, and 24 h postoperatively at rest and when coughing. Conclusions Ultrasound-guided bi-level ESPBs provided better postoperative analgesia than PECS blocks after radical mastectomy surgery

Meme kanserinde siklooksijen az-2 ekspresyonu artışının sağkalım üzerine etkisi

ÖZETMeme kanseri kadınlarda görülen en sık kanserdir. Bu kanserin görülme hızı hergeçen gün daha da artmaktadır. Prostaglandin sentezinde görevli ana enzim olansiklooksijenaz-2 (COX-2) enziminin bir çok kanser tipinde olduğu gibi memekanserinde de ekspresyonunun arttığı gösterilmiĢtir. Günümüzde meme kanserinindeğerlendirilmesinde ve tedavisinde kullanılan bazı prognostik ve prediktif faktörlervardır. ÇalıĢmalar COX-2’nin meme kanseri sağkalımını da tahmin ettirebilecekprognostik ve prediktif bir faktör olabileceği konusunda iĢaretler ortaya koymuĢtur.Bu çalıĢmanın amacı meme kanseri sağkalımı ile COX-2 ekspresyonundakiartıĢ arasındaki iliĢkiyi göstermektir. ÇalıĢmanın hipotezi, COX-2 ekspresyonundakiartıĢın meme kanseri sağkalımı ile ters orantılı olduğudur.ÇalıĢmada COX-2 ekspresyonunun genel sağkalım (GS), hastalıksız sağkalım(HS) ve meme kanserine özgün sağkalım (MKÖS) üzerine etkileri ortayakoyulmuĢtur. COX-2 ekspresyonu ile meme kanserinin prognostik faktörleriarasındaki iliĢki, GS, HS ve MKÖS’yi etkileyen bağımsız faktörler ve moleküler altgruplarda COX-2 ekspresyonunun GS, HS ve MKÖS üzerine etkileri gösterilmeyeçalıĢılmıĢtır.ÇalıĢmanın sonucunda COX-2 ekspresyonunun GS, HS ve MKÖS üzerineanlamlı bir etkisinin olmadığı gösterilmiĢtir. Buna rağmen takip süreleri ilerledikçeGS ve MKÖS için COX-2 ekspresyonu pozitif olan hastaların sağkalımlarının dahakötüye gittiği görülmüĢtür. COX-2 ekspresyonu ile Ki67 ekspresyonu arasındaanlamlı bir iliĢki olduğu, Ki67’si pozitif hastaların COX-2 ekspresyon düzeyinin deyüksek olduğu gösterilmiĢtir. Sadece progesteron reseptör pozitifliğinin GS veMKÖS’yi etkilediği, PR negatif olmasının GS ve MKÖS’yi azalttığı gösterilmiĢtir.Tümör çapının artmasının ve moleküler alt gruplandırmada luminal B tip ve bazal tipolmanın HS’yi azalttığı gösterilmiĢtir. Moleküler alt gruplar değerlendirmesinde iseher alt grup içinde COX-2 ekspresyonunun negatif veya pozitif olmasının o altgrubun sağkalımı üzerine etkisinin olmadığı görülmüĢtür.ANAHTAR SÖZCÜKLER : meme kanseri, sağkalım, siklooksijenaz-2 enzimi,prognostik faktör, prediktif faktörSUMMARYBreast cancer is the most common cancer in Turkish women and its incidence isincreasing in time. Overexpression of cyclooxygenase-2 (COX-2), a major enzymefor prostaglandin synthesis, is also found in breast cancer. There are currentpredictive and prognostic factors of breast cancer which are taken underconsideration for treatment assignment. Previous data revealed that COX-2expression is also a promising predictive and prognostic factor for breast cancer.Aim of this present study is to assess the impact of COX-2 expression onbreast cancer survival. Hypothesis was determined as COX-2 overexpression isrelated with poor prognosis in breast cancer patients.The study assessed rates of overall (OS), disease free (DFS) and breast cancerspecific survival (BCSS) in patients with and without COX-2 overexpression inretrospective manner. In addition, relation between COX-2 expression and otherconventional prognostic factors such as tumor size, grade and hormone receptorexpression for breast cancer was assessed. Independent factors for OS, DFS andBCSS and the impact of COX-2 expression on OS, DFS as well as BCSS wasanalyzed in each molecular subgroup of breast cancer.As result, OS, DFS and BCSS rates were not different in patients with COX-2negative and positive breast cancer. Ki67 expression was significantly increased inCOX-2 overexpressed patients. Progesteron receptor expression was found to be theindependent factor for both OS and BCSS, in which progesteron receptor negativepatients had significantly poorer survival rates. Additionally, increasing tumor sizeand molecular subtypes of luminal B and basal types were the independent predictivefactors for poorer DFS. Survival rates were also similar within each molecularsubgroup irrespective of their COX-2 overexpression.KEY WORDS : breast cancer, survival, cyclooxygenase -2 enzyme, prognosticfactors, predictive factor

Association of biochemical and clinical parameters with parathyroid adenoma weight. Turkish-Bulgarian endocrine and breast surgery study group, hyperparathyroidism registry study

Background: Primary hyperparathyroidism (pHPT) caused by a single benign parathyroid adenoma is a common endocrine disorder that is affected by regional differences. Living in different geographical regions reveals differences in the laboratory results and pathological findings, but studies on this subject are not sufficient. The article focuses on biochemical and pathological effects of geographical differences in parathyroid adenoma. In addition, the present study seeks to elaborate on treatment methods and effectiveness of screening in geographical area of Bulgaria and Turkey. Method: In this prospective study, 159 patients were included from 16 centres. Demographic characteristics, symptoms, biochemical markers and pathologic characteristics were analysed and compared between 8 different regions. Results: Patients from Turkish Black Sea had the highest median serum calcium (Ca) level, whereas patients from Eastern Turkey had the lowest median serum phosphorus (P) level. On the other hand, there was no significant difference between Ca, parathormone (PTH) and P levels according to regions. Patients from Eastern Turkey had the highest adenoma weight, while patients from Bulgaria had the lowest adenoma weight. The weight of adenoma showed statistically significant differences between regions (p < 0.001). There was a correlation between adenoma weight and serum PTH level (p = 0.05) and Ca level (p = 0.035). Conclusion: This study has provided a deeper insight into the effect of the regional differences upon clinicopathological changing and biochemical values of pHTP patients with adenoma. Awareness of regional differences will assist in biochemical screening and treatment of this patient group. (c) 2021 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/)

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research