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A Systematic Review and Meta-Analysis of the Effect of Intraoperative Bupivacaine in Gynaecologic Surgery After 24 Hours or 9 Half-Lives.
Marchand, GJ, Masoud, AT, Ware, K, King, A, Ruther, S, Brazil, G, Cieminski, K, Calteux, N, Coriell, C, Ulibarri, H, et al
Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC. 2021;(11):1279-1287
Abstract
OBJECTIVE To review all high quality available evidence regarding the effect of intraoperative bupivacaine 24 hours (or 8.9 half-lives) after intraoperative administration at time of gynaecologic surgery and to ascertain whether a second mechanism of action, beyond the initial prevention of sodium channel depolarization and blockade of nerve impulses, may be occurring. DATA SOURCES We searched all major databases with an algorithm designed to include all randomized trials that used any form of local bupivacaine, regardless of dose or route of administration, at the time of any gynaecologic surgery and compared its use with saline placebo. RESULTS As expected, we found that bupivacaine showed a significant improvement for all gynaecologic surgeries with respect to pain intensity at 6 hours after surgery when compared with a saline group (mean difference [MD] -1.28; 95% CI -1.96 to -0.61], P = 0.07). We also found a significant difference at 24 hours after surgery, giving evidence to the possibility of a second mechanism of action (MD -0.57; 95% CI -1.10 to -0.05], P = 0.01). Further subgroup analysis for pain levels at 24 hours showed significant decreases in pain for the laparoscopy (MD -0.74; 95% CI -0.93 to -0.54, P < 0.01) and laparotomy (MD -2.60; 95% CI -2.93 to -2.27, P < 0.01)) subgroups but not for the vaginal hysterectomy (MD 0.20; 95% CI -0.69 to 1.09, P = 0.66) or prolapse surgery (MD -0.11; 95% CI -0.41 to 0.19, P = 0.48) subgroups. There was no significant difference with respect to the length of hospital stay (MD -0.11; 95% CI -0.59 to 0.38, P = 0.67). CONCLUSION As expected, bupivacaine significantly reduced visual analog pain scores when compared with placebo at 6 hours after surgery, but also showed a significant difference at 24 hours after surgery, giving evidence of a second mechanism of action following the initial sodium channel blockade.
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Assessment of Body Composition as an Indicator of Early Peripheral Parenteral Nutrition Therapy in Patients Undergoing Colorectal Cancer Surgery in an Enhanced Recovery Program.
López-Rodríguez-Arias, F, Sánchez-Guillén, L, Lillo-García, C, Aranaz-Ostáriz, V, Alcaide, MJ, Soler-Silva, Á, Soriano-Irigaray, L, Barber, X, Arroyo, A
Nutrients. 2021;(9)
Abstract
BACKGROUND A poor body composition (BC) has been identified as a risk factor for patients with colorectal cancer (CRC). This study was performed to assess the effect of early peripheral parenteral nutrition (PPN) on BC in patients undergoing CCR surgery within an enhanced recovery program. METHODS Patients with normal nutritional status were prospectively included between October 2016 and September 2019, randomized into two groups (PPN with periOlimel N4-E versus conventional fluid therapy) and subsequently classified according to their preoperative CT scan into high- or low-risk BC groups. Postoperative complications and length of hospital stay (LOS) were assessed. RESULTS Of the 156 patients analyzed, 88 patients (56.4%) were classified as having high-risk BC according to CT measurements. PPN led to a 15.4% reduction in postoperative complications in high-risk vs. 1.7% in low-risk BC patients. In the multivariate analysis, high-risk BC was related to an OR (95% CI) of 2 (p = 0.044) of presenting complications and of 1.9 (p = 0.066) for major complications, and was associated with an increase in LOS of 3.6 days (p = 0.039). CONCLUSIONS The measurement of patients' BC can allow for the identification of target patients where PPN has been proven to be an effective tool to improve postoperative outcomes.
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A Narrative Review About Prehabilitation in Surgery: Current Situation and Future Perspectives.
López Rodríguez-Arias, F, Sánchez-Guillén, L, Armañanzas Ruiz, LI, Díaz Lara, C, Lacueva Gómez, FJ, Balagué Pons, C, Ramírez Rodríguez, JM, Arroyo, A
Cirugia espanola. 2020;(4):178-186
Abstract
Prehabilitation has a multimodal conception based on three fundamental pillars: improvement of the patient's physical condition, nutritional optimization and cognitive intervention to reduce stress and anxiety, as well as other measures such as smoking cessation and correction of anemia. The aim of prehabilitation programs is to optimize the patient from the moment of diagnosis until the surgical intervention in order to reduce postoperative complications. As in the case of multimodal rehabilitation protocols, the actions of prehabilitation programs have synergistic effects, that is, small changes that, by themselves, do not have clinical significance but when added up, they produce a significant improvement in the postoperative evolution of patients. Although more studies are required to evaluate the impact of these programs on patients groups with different pathologies, interventions and risk factors, their progressive implementation is necessary in the daily clinical practice of our patients. The objective of this narrative review is to evaluate the available evidence about prehabilitation in surgery, focusing on current established strategies, knowledge gaps and future research.
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Maternal and child health services and an integrated, life-cycle approach to the prevention of non-communicable diseases.
Brumana, L, Arroyo, A, Schwalbe, NR, Lehtimaki, S, Hipgrave, DB
BMJ global health. 2017;(3):e000295
Abstract
Described as the 'invisible epidemic', non-communicable diseases (NCDs) are the world's leading cause of death. Most are caused by preventable factors, including poor diet, tobacco use, harmful use of alcohol and physical inactivity. Diabetes, cancer and cardiovascular and chronic lung diseases were responsible for 38 million (68%) of global deaths in 2012. Since 1990, proportionate NCD mortality has increased substantially as populations have aged and communicable diseases decline. The majority of NCD deaths, especially premature NCD deaths (<70 years, 82%), occur in low-income and middle-income countries, and among poor communities within them. Addressing NCDs is recognised as central to the post-2015 agenda; accordingly, NCDs have a specific objective and target in the Sustainable Development Goals. While deaths from NCDs occur mainly in adulthood, many have their origins in early life, including through epigenetic mechanisms operating before conception. Good nutrition before conception and interventions aimed at preventing NCDs during the first 1000 days (from conception to age 2 years), childhood and adolescence may be more cost-effective than managing established NCDs in later life with costly tests and drugs. Following a life-course approach, maternal and child health interventions, before delivery and during childhood and adolescence, can prevent NCDs and should influence global health and socioeconomic development. This paper describes how such an approach may be pursued, including through the engagement of non-health sectors. It also emphasises evaluating and documenting related initiatives to underwrite systematic and evidence-based cross-sectoral engagement on NCD prevention in the future.
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Perioperative immunonutrition in normo-nourished patients undergoing laparoscopic colorectal resection.
Moya, P, Miranda, E, Soriano-Irigaray, L, Arroyo, A, Aguilar, MD, Bellón, M, Muñoz, JL, Candela, F, Calpena, R
Surgical endoscopy. 2016;(11):4946-4953
Abstract
OBJECTIVE To determine whether the joint implementation of immunonutrition and a laparoscopic approach improves morbidity, mortality, and length of stay (LOS) compared with dietary advice. BACKGROUND Despite progress in recent years in the surgical management of patients with colorectal cancer, postoperative complications are frequent. Nutritional supplements enriched with immunonutrients have recently been introduced into clinical practice. However, the immunonutrition benefits in patients undergoing colorectal laparoscopic surgery are unknown. METHODS This study was a prospective, randomized trial with two parallel treatment groups receiving an immune-enhancing dietary supplement for 7 days before colorectal resection and 5 days postoperatively or dietary advice. RESULTS A total of 128 patients were randomized. At baseline, both groups were comparable with respect to age, sex, surgical risk, comorbidities, and analytical and nutritional parameters. The median postoperative LOS was 5 days and was not significantly different between the groups. Wound infection differed significantly between the groups (11.50 vs. 0.00 %, p = 0.006). No other differences between the groups were identified. CONCLUSIONS The joint use of laparoscopy and supplementation with immunonutrients reduces surgical wound infection in patients undergoing colorectal surgery. TRIAL REGISTRATION This study is registered with ClinicalTrial.gov : NCT0239396.
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Perioperative Standard Oral Nutrition Supplements Versus Immunonutrition in Patients Undergoing Colorectal Resection in an Enhanced Recovery (ERAS) Protocol: A Multicenter Randomized Clinical Trial (SONVI Study).
Moya, P, Soriano-Irigaray, L, Ramirez, JM, Garcea, A, Blasco, O, Blanco, FJ, Brugiotti, C, Miranda, E, Arroyo, A
Medicine. 2016;(21):e3704
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Abstract
To compare immunonutrition versus standard high calorie nutrition in patients undergoing elective colorectal resection within an Enhanced Recovery After Surgery (ERAS) program.Despite progress in recent years in the surgical management of patients with colorectal cancer (ERAS programs), postoperative complications are frequent. Nutritional supplements enriched with immunonutrients have recently been introduced into clinical practice. However, the extent to which the combination of ERAS protocols and immunonutrition benefits patients undergoing colorectal cancer surgery is unknown.The SONVI study is a prospective, multicenter, randomized trial with 2 parallel treatment groups receiving either the study product (an immune-enhancing feed) or the control supplement (a hypercaloric hypernitrogenous supplement) for 7 days before colorectal resection and 5 days postoperatively.A total of 264 patients were randomized. At baseline, both groups were comparable in regards to age, sex, surgical risk, comorbidity, and analytical and nutritional parameters. The median length of the postoperative hospital stay was 5 days with no differences between the groups. A decrease in the total number of complications was observed in the immunonutrition group compared with the control group, primarily due to a significant decrease in infectious complications (23.8% vs. 10.7%, P = 0.0007). Of the infectious complications, wound infection differed significantly between the groups (16.4% vs. 5.7%, P = 0.0008). Other infectious complications were lower in the immunonutrition group but were not statistically significantly different.The implementation of ERAS protocols including immunonutrient-enriched supplements reduces the complications of patients undergoing colorectal resection.This study is registered with ClinicalTrial.gov: NCT02393976.
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Percutaneous electrical neurostimulation of dermatome T6 for appetite reduction and weight loss in morbidly obese patients.
Ruiz-Tovar, J, Oller, I, Diez, M, Zubiaga, L, Arroyo, A, Calpena, R
Obesity surgery. 2014;(2):205-11
Abstract
BACKGROUND A continuous feeling of hunger is the major cause of dietary treatment failure in obese patients, making dietary leave. The aim of this study was to evaluate the effect of percutaneous electrical neurostimulation (PENS) of T6 dermatome on appetite, weight loss and dietary compliance. METHODS A prospective, randomized study was performed. The patients were randomized into two groups: those undergoing PENS of dermatome T6 associated with the implementation of a 1,200-Kcal diet (group 1) and those following only a 1,200-Kcal diet (group 2). A third group of obese patients (BMI > 30 Kg/m(2)) with fecal incontinence undergoing PENS of posterior tibial nerve was evaluated. RESULTS One hundred five patients were included in the study, 45 in groups 1 and 2, and 15 in group 3. The median pain perception after PENS of dermatome T6 was 1. There were no complications. Only the patients in group 1 experienced significant reductions of weight, BMI, and appetite. All of the patients in group 1 experienced appetite reduction compared to 20 % of the patients in group 2 and 30 % of the patients in group 3 (p < 0.001). Weight loss ≥5 Kg was achieved in 76.7 % of the patients in group 1, 6.7 % of the patients in group 2, and 0 % of the patients in group 3 (p < 0.001). Dietary compliance after 12 weeks was 93.3 % in group 1, 56.7 % in group 2, and 50 % in group 3(p = 0.006). CONCLUSIONS PENS of dermatome T6 was associated with appetite reduction in all of the patients and, along with a proper diet, achieved a significantly greater weight reduction than diet alone.
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Hair loss in females after sleeve gastrectomy: predictive value of serum zinc and iron levels.
Ruiz-Tovar, J, Oller, I, Llavero, C, Zubiaga, L, Diez, M, Arroyo, A, Calero, A, Calpena, R
The American surgeon. 2014;(5):466-71
Abstract
A common complication after bariatric surgery is hair loss, which is related to rapid weight reduction, but zinc, iron, and other micronutrient deficiencies can also be involved. Little is studied after laparoscopic sleeve gastrectomy (LSG). A prospective observational study was performed of 42 morbidly obese females undergoing LSG. Incidence of hair loss was monitored. Micronutrients were investigated preoperatively and three, six, and 12 months after surgery. Sixteen patients (41%) reported hair loss in the postoperative course. A significant association was observed between hair loss and zinc levels (P = 0.021) but mean zinc levels were within the normal range in patients reporting hair loss. Only three patients (7.7%) presented low zinc levels, all of them reporting hair loss. There was also a significant association between iron levels and alopecia (P = 0.017), but mean values of the patients with hair loss were within normal range. Only four patients (10.2%) presented low iron levels, all of them presenting hair loss. A variable consisting of the addition of zinc + iron showed a significant association with hair loss (P = 0.013). A cutoff point was established in 115 (odds ratio, 4; P = 0.006). All the patients but two reporting hair loss presented addition levels under 115. This variable showed sensibility 88 per cent, specificity 84 per cent, positive predictive value 79 per cent, and negative predictive value 91 per cent to predict hair loss. Hair loss is a frequent condition after sleeve gastrectomy. In most cases, iron and zinc levels are within the normal range. The variable addition (zinc + iron) is a good predictor of hair loss. Patients with addition levels below 115 are fourfold more susceptible to present hair loss. In these cases, zinc supplements achieve the stop of hair loss in most cases.
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Short- and mid-term changes in bone mineral density after laparoscopic sleeve gastrectomy.
Ruiz-Tovar, J, Oller, I, Priego, P, Arroyo, A, Calero, A, Diez, M, Zubiaga, L, Calpena, R
Obesity surgery. 2013;(7):861-6
Abstract
BACKGROUND Bariatric surgery is the most effective treatment for achieving a significant weight loss. Morbidities present a significant reduction after bariatric surgery, but it may also result in several health complications, related to nutritional deficiencies, including bone metabolism. Several studies have reported a decrease in bone mineral density (BMD), but most of them referring to malabsorptive procedures. Restrictive procedures do not imply changes in gastrointestinal anatomy, so that one may expect fewer metabolic disturbances. METHODS We performed a retrospective observational study of all morbidly obese patients undergoing LSG between 2008 and 2011 at our institution. Bone densitometry was performed before surgery and 1 and 2 years after the intervention. Body size measurements, analytical variables and densitometric values in the lumbar spine (BMD, t score and z score) were investigated. RESULTS Forty-two patients were included, 39 females and 3 males. Mean BMI was 51.21 kg/m(2). Mean excessive BMI loss was 79.9 % after 1 year and 80.6 % after 2 years. Mean BMD values for spine increased progressively, reaching statistical significance at 1 and at 2 years. Percentage of BMD increase was 5.7 % at 1 year and 7.9 % at 2 years. An inverse correlation was observed between BMD increase and parathyroid hormone (PTH) decrease and a direct correlation between BMD and vitamin D increase. CONCLUSION Bone mineral density showed a progressive increase during the first and second year after sleeve gastrectomy. BMD changes are not associated with weight loss, but showed a direct correlation with vitamin D and an inverse correlation with PTH levels.
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Heavy metal poisoning: management of intoxication and antidotes.
Rusyniak, DE, Arroyo, A, Acciani, J, Froberg, B, Kao, L, Furbee, B
EXS. 2010;:365-96
Abstract
Of the known elements, nearly 80% are either metals or metalloids. The highly reactive nature of most metals result in their forming complexes with other compounds such oxygen, sulfide and chloride. Although this reactivity is the primary means by which they are toxic, many metals, in trace amounts, are vital to normal physiological processes; examples include iron in oxygen transport, manganese and selenium in antioxidant defense and zinc in metabolism. With these essential metals toxicity occurs when concentrations are either too low or too high. For some metals there are no physiological concentrations that are beneficial; as such these metals only have the potential to cause toxicity. This chapter focuses on four of these: arsenic, mercury, lead and thallium.