Effect of thoracic epidural anesthesia on postoperative outcome in major liver surgery: a retrospective cohort study.

PURPOSE: Postoperative complications after major liver surgery are common. Thoracic epidural anesthesia may provide beneficial effects on postoperative outcome. We strove to compare postoperative outcomes in major liver surgery patients with and without thoracic epidural anesthesia. METHODS: This was a retrospective cohort study in a single university medical center. Patients undergoing elective major liver surgery between April 2012 and December 2016 were eligible for inclusion. We divided patients into two groups according to whether or not they had thoracic epidural anesthesia for major liver surgery. The primary outcome was postoperative hospital length of stay, i.e., from day of surgery until hospital discharge. Secondary outcomes included 30-day postoperative mortality and major postoperative complications. Additionally, we investigated the effect of thoracic epidural anesthesia on perioperative analgesia doses and the safety of thoracic epidural anesthesia. RESULTS: Of 328 patients included in this study, 177 (54.3%) received thoracic epidural anesthesia. There were no clinically important differences in postoperative hospital length of stay (11.0 [7.00-17.0] vs. 9.00 [7.00-14.0] days, p = 0.316, primary outcome), death (0.0 vs. 2.7%, p = 0.995), or the incidence of postoperative renal failure (0.6 vs. 0.0%, p = 0.99), sepsis (0.0 vs. 1.3%, p = 0.21), or pulmonary embolism (0.6 vs. 1.4%, p = 0.59) between patients with or without thoracic epidural anesthesia. Perioperative analgesia doses - including the intraoperative sufentanil dose (0.228 [0.170-0.332] vs. 0.405 [0.315-0.565] µg·kg-1·h-1, p < 0.0001) - were lower in patients with thoracic epidural anesthesia. No major thoracic epidural anesthesia-associated infections or bleedings occurred. CONCLUSION: This retrospective analysis suggests that thoracic epidural anesthesia does not reduce postoperative hospital length of stay in patients undergoing major liver surgery - but it may reduce perioperative analgesia doses. Thoracic epidural anesthesia was safe in this cohort of patients undergoing major liver surgery. These findings need to be confirmed in robust clinical trials.

Mandatory substance use treatment for justice-involved persons in Germany: a systematic review of reoffending, treatment and the recurrence of substance use outcomes.

Many jurisdictions implement mandatory substance use treatment for justice-involved persons. Germany is one such country; however, debates about the appropriateness and effectiveness of this disposal abound. Very little attention has been paid in the international literature to patients receiving mandatory treatment in Germany. This systematic review synthesises research on patients receiving substance use treatment in forensic hospitals under §64 of the German Penal Code with regard to three primary outcomes: treatment completion, reoffending, and the recurrence of substance use. Forty-five publications reporting on 36 studies were reviewed; publication dates ranged from 1988 to 2023. On average, 47% of patients did not successfully complete treatment, compared to 45% who did. Average follow-up reconviction rates were higher than in mentally ill and general offender populations as reported elsewhere. Approximately half of all patients reused substances during treatment. Suggestions for future research, including a focus on strength- and recovery-based indicators, and harmonising routine outcomes measurements, are given.