Comment prévenir la douleur après une chirurgie du sein : une revue systématique avec méta-analyse et analyse séquentielle

La chirurgie du sein est une chirurgie fréquente pouvant provoquer des douleurs postopératoires invalidantes. Plusieurs interventions pharmacologiques peuvent être proposées afin de prévenir l'apparition de douleurs. Nous avons réalisé une revue systématique afin de déterminer quelles interventions sont les plus efficaces. L’issue principale était la douleur aiguë postopératoire. Les issues secondaires étaient la consommation cumulée de morphine sur 24h, l’incidence des nausées et vomissements postopératoires, et la douleur chronique. La recherche systématique dans les bases de données a permis d'identifier 73 études randomisées. Les résultats après méta-analyse et analyse séquentielle (trial sequential analysis) montrent que les blocs paravertébraux et pectoraux et les glucocorticoïdes intra-veineux sont les interventions les plus efficaces pour diminuer la douleur aiguë postopératoire. La lidocaïne intra-veinsuese et les agonistes alpha-2 sont également efficaces mais dans une moindre mesure. Les données sont insuffisantes pour tirer des conclusions en ce qui concerne la prévention de la douleur chronique.</p

Hypogonadotropic hypogonadism among a population of obese men: Prevalence, risk factors and reversibility after weight loss induced by bariatric surgery

Background and aims: Obesity in men is frequently associated with low levels of testosterone, loss of libido and/or erectile dysfunction. Our goal was to estimate the prevalence of hypogonadism among obese men and to determine its risk factors and reversibility after bariatric surgery. Methods: Seventy-five obese men were studied at baseline. Metabolic and hormonal parameters were measured, body composition was assessed by bioelectrical impedance and hypogonadism was evaluated by the ADAM (Androgen Deficiency in Aging Males) questionnaire. Twenty-one patients were re-evaluated after bariatric surgery. Results: At baseline, 39% of obese men had hypotestosteronemia, while symptoms of androgen deficiency were present in 93%. Total Testosterone (TT) was inversely related to body mass index (BMI) (. P<. 0.05), waist circumference (. P=. 0.012) and body fat mass (. P=. 0.022). Bariatric surgery was associated with an increase in TT (. P=. 0.001) and decreases in estradiol (E2) (. P=. 0.008) and in the E2/TT ratio (. P=. 0.001). Conclusions: Low testosterone levels are frequently observed among morbidly obese men and are correlated with the degree of abdominal adiposity, but not strongly with the presence of sexual dysfunction. Bariatric surgery leads to normalized TT and to decreased E2 and E2/TT ratio, suggesting a role of excessive aromatization in the hypotestosteronemia associated with obesity

Preventing pain after breast surgery: A systematic review with meta‐analyses and trial‐sequential analyses

Background and objective: The aim of this systematic review was to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast surgery. Databases and data treatment: We searched for randomized trials comparing analgesic interventions with placebo or no treatment in patients undergoing breast surgery under general anaesthesia. Primary outcome was intensity of acute pain (up to 6 hr postoperatively). Secondary outcomes were cumulative 24-hr morphine consumption, incidence of postoperative nausea and vomiting (PONV), and chronic pain. We used an original three-step approach. First, meta-analyses were performed when data from at least three trials could be combined; secondly, trial sequential analyses were used to separate conclusive from unclear evidence. And thirdly, the quality of evidence was rated with GRADE. Results: Seventy-three trials (5,512 patients) tested loco-regional blocks (paravertebral, pectoralis), local anaesthetic infiltrations, oral gabapentinoids or intravenous administration of glucocorticoids, lidocaine, N-methyl-D-aspartate antagonists or alpha2 agonists. With paravertebral blocks, pectoralis blocks and glucocorticoids, there was conclusive evidence of a clinically relevant reduction in acute pain (visual analogue scale &gt; 1.0 cm). With pectoralis blocks, and gabapentinoids, there was conclusive evidence of a reduction in the cumulative 24-hr morphine consumption (&gt; 30%). With paravertebral blocks and glucocorticoids, there was conclusive evidence of a relative reduction in the incidence of PONV of 70%. For chronic pain, insufficient data were available. Conclusions: Mainly with loco-regional blocks, there is conclusive evidence of a reduction in acute pain intensity, morphine consumption and PONV incidence after breast surgery. For rational decision making, data on chronic pain are needed. Significance: This quantitative systematic review compares eight interventions, published across 73 trials, to prevent pain after breast surgery, and grades their degree of efficacy. The most efficient interventions are paravertebral blocks, pectoralis blocks and glucocorticoids, with moderate to low evidence for the blocks. Intravenous lidocaine and alpha2 agonists are efficacious to a lesser extent, but with a higher level of evidence. Data for chronic pain are lacking.</p