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A narrative review on the non-surgical treatment of chronic postoperative inguinal pain: a challenge for both surgeon and anaesthesiologist.
van Veenendaal, N, Foss, NB, Miserez, M, Pawlak, M, Zwaans, WAR, Aasvang, EK
Hernia : the journal of hernias and abdominal wall surgery. 2023;(1):5-14
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INTRODUCTION Chronic pain is one of the most frequent clinical problems after inguinal hernia surgery. Despite more than two decades of research and numerous publications, no evidence exists to allow for chronic postoperative inguinal pain (CPIP) specific treatment algorithms. METHODS This narrative review presents the current knowledge of the non-surgical management of CPIP and makes suggestions for daily practice. RESULTS There is a paucity for high-level evidence of non-surgical options for CPIP. Different treatment options and algorithms have been published for chronic pain patients in the last decades. DISCUSSION AND CONCLUSION It is suggested that non-surgical treatment is introduced in the management of all CPIP patients. The overall approach to interventions should be pragmatic, tiered and multi-interventional, starting with least invasive and only moving to more invasive procedures upon lack of effect. Evaluation should be multidisciplinary and should take place in specialized centres. We strongly suggest to follow general guidelines for treatment of persistent pain and to build a database allowing for establishing CPIP specific evidence for optimal analgesic treatments.
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Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care.
Scott, MJ, Aggarwal, G, Aitken, RJ, Anderson, ID, Balfour, A, Foss, NB, Cooper, Z, Dhesi, JK, French, WB, Grant, MC, et al
World journal of surgery. 2023;(8):1850-1880
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BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient.
Peden, CJ, Aggarwal, G, Aitken, RJ, Anderson, ID, Balfour, A, Foss, NB, Cooper, Z, Dhesi, JK, French, WB, Grant, MC, et al
World journal of surgery. 2023;(8):1881-1898
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BACKGROUND This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Bioimpedance spectroscopy fluid analysis in acute high-risk abdominal surgery, a prospective clinician-blinded observational feasibility study.
Cihoric, M, Kehlet, H, Højlund, J, Lauritsen, ML, Kanstrup, K, Foss, NB
Journal of clinical monitoring and computing. 2023;(2):619-627
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Objective assessment of fluid status in critical surgical care may help optimize perioperative fluid administration and prevent postoperative fluid retention. We evaluated the feasibility of hydration status and fluid distribution assessment by Bioimpedance spectroscopy Analysis (BIA) in patients undergoing acute high-risk abdominal (AHA) surgery. This observational study included 73 patients undergoing AHA surgery. During the observational period (0-120 h), we registered BIA calculated absolute fluid overload (AFO) and relative fluid overload (RFO), defined as AFO/extracellular water ratio, as well as cumulative fluid balance and weight. Based on RFO values, hydration status was classified into three categories: dehydrated (RFO < - 10%), normohydrated (- 10% ≤ RFO ≤ + 15%), overhydrated RFO > 15%. We performed a total of 365 BIA measurements. Preoperative overhydration was found in 16% of patients, increasing to 66% by postoperative day five. The changes in BIA measured AFO correlated with the cumulative fluid balance (r2 = 0.44, p < .001), and change in weight (r2 = 0.55, p < .0001). Perioperative overhydration measured with BIA was associated with worse outcome compared to patients with normo- or dehydration. We have demonstrated the feasibility of obtaining perioperative bedside BIA measurements in patients undergoing AHA surgery. BIA measurements correlated with fluid balance, weight changes, and postoperative clinical complications. BIA-assessed fluid status might add helpful information to guide fluid management in patients undergoing AHA surgery.
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Feasibility and preliminary effect of anabolic steroids in addition to strength training and nutritional supplement in rehabilitation of patients with hip fracture: a randomized controlled pilot trial (HIP-SAP1 trial).
Hulsbæk, S, Bandholm, T, Ban, I, Foss, NB, Jensen, JB, Kehlet, H, Kristensen, MT
BMC geriatrics. 2021;(1):323
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BACKGROUND Anabolic steroid has been suggested as a supplement during hip fracture rehabilitation and a Cochrane Review recommended further trials. The aim was to determine feasibility and preliminary effect of a 12-week intervention consisting of anabolic steroid in addition to physiotherapy and nutritional supplement on knee-extension strength and function after hip fracture surgery. METHODS Patients were randomized (1:1) during acute care to: 1. Anabolic steroid (Nandrolone Decanoate) or 2. Placebo (Saline). Both groups received identical physiotherapy (with strength training) and a nutritional supplement. Primary outcome was change in maximal isometric knee-extension strength from the week after surgery to 14 weeks. Secondary outcomes were physical performance, patient reported outcomes and body composition. RESULTS Seven hundred seventeen patients were screened, and 23 randomised (mean age 73.4 years, 78% women). Target sample size was 48. Main limitations for inclusion were "not home-dwelling" (18%) and "cognitive dysfunction" (16%). Among eligible patients, the main reason for declining participation was "Overwhelmed and stressed by situation" (37%). Adherence to interventions was: Anabolic steroid 87%, exercise 91% and nutrition 61%. Addition of anabolic steroid showed a non-significant between-group difference in knee-extension strength in the fractured leg of 0.11 (95%CI -0.25;0.48) Nm/kg in favor of the anabolic group. Correspondingly, a non-significant between-group difference of 0.16 (95%CI -0.05;0.36) Nm/Kg was seen for the non-fractured leg. No significant between-group differences were identified for the secondary outcomes. Eighteen adverse reactions were identified (anabolic = 10, control = 8). CONCLUSIONS Early inclusion after hip fracture surgery to this trial seemed non-feasible, primarily due to slow recruitment. Although inconclusive, positive tendencies were seen for the addition of anabolic steroid. TRIAL REGISTRATION Clinicaltrials.gov NCT03545347 .
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Challenges in optimising recovery after emergency laparotomy.
Foss, NB, Kehlet, H
Anaesthesia. 2020;:e83-e89
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Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.
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Preliminary effect and feasibility of physiotherapy with strength training and protein-rich nutritional supplement in combination with anabolic steroids in cross-continuum rehabilitation of patients with hip fracture: protocol for a blinded randomized controlled pilot trial (HIP-SAP1 trial).
Hulsbæk, S, Ban, I, Aasvang, TK, Jensen, JB, Kehlet, H, Foss, NB, Bandholm, T, Kristensen, MT
Trials. 2019;(1):763
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BACKGROUND A 2014 Cochrane review evaluating the effect of anabolic steroids after hip fracture concluded that the quality of the studies was insufficient to draw conclusions on the effects and recommended further high-quality trials in the field. Therefore, the aim of this pilot trial is to determine the preliminary effect and feasibility of a 12-week multimodal intervention consisting of physiotherapy (with strength training), protein-rich nutritional supplement and anabolic steroid on knee-extension muscle strength and function 14 weeks after hip fracture surgery. METHODS We plan to conduct a randomized, placebo-controlled pilot trial with 48 patients operated for acute hip fracture. The patients are randomized (1:1) to either (1) physiotherapy with protein-rich nutritional supplement plus anabolic steroid or (2) physiotherapy with protein-rich nutritional supplement plus placebo. Outcome assessments will be carried out blinded at baseline (3-10 days after surgery) and at 14 weeks after entering the trial. Primary outcome is the change from baseline to follow-up in maximal isometric knee-extension muscle strength in the fractured limb. Secondary outcomes are physical performance test, patient-reported outcomes, and measures of body composition. DISCUSSION If the trial is found feasible and the results show an indication of anabolic steroid being a relevant addition to further enhance the recovery of muscle strength and function in an enhanced recovery after surgery program, this trial will constitute the basis of a larger confirmatory trial. TRIAL REGISTRATION ClinicalTrials.gov, NCT03545347. Preregistered on 4 June 2018.
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Methylprednisolone and inflammatory stress response in older people undergoing surgery for hip fracture: a secondary analysis of a randomized controlled trial.
Clemmesen, CG, Tavenier, J, Andersen, O, Palm, H, Foss, NB
European geriatric medicine. 2019;(6):913-921
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PURPOSE The inflammatory response to surgery can cause organ dysfunction that results in postoperative complications, including delirium. Methylprednisolone is an anti-inflammatory drug and could mitigate stress responses. This purpose of the study is to investigate the effects of a single high-dose methylprednisolone on various biomarkers in older people undergoing surgery for hip fractures. METHODS In the primary study, 117 patients were included. The biomarkers investigated in this secondary analysis were interleukin (IL) -6, IL-10, troponin-T (TnT), tumor necrosis factor alpha (TNF-α), S100 calcium-binding protein B, and soluble urokinase-type plasminogen activator receptor. Blood samples were collected at four time points: (1) before the study intervention (Tbefore); (2) at time of surgery (Tsurgery); on the (3) 1st and (4) 3rd postoperative day (TP1 and TP3, respectively). RESULTS Patients in the methylprednisolone group had significantly lower adjusted mean IL-6 at Tsurgery and TP1 than the placebo group [15.60 (1.13 pg/mL) vs 47.86 (1.12 pg/mL), p < 0.000 and 111.01 (31.64 pg/mL) vs 198.57 (24.00 pg/mL), p = 0.005]. Furthermore, adjusted mean TnT levels at Tsurgery were lower in the methylprednisolone group [20.61 (1.14 ng/mL) vs 24.28 (1.12 ng/mL), p = 0.024) as well as adjusted mean TNF-α levels TP1 (14.31 (1.08 pg/mL) vs 17.64 (1.04 pg/mL), p = 0.025]. CONCLUSIONS In this secondary analysis, methylprednisolone had a significant effect on three biomarkers (IL-6, TnT, and TNF-α). The potential beneficial effects of methylprednisolone on inflammatory biomarkers reflecting surgical stress response in patients with hip fractures need to be investigated further.