Umbrella review and network meta-analysis of diagnostic imaging test accuracy studies in Differentiating between brain tumor progression versus pseudoprogression and radionecrosis.

PURPOSE: In this study we gathered and analyzed the available evidence regarding 17 different imaging modalities and performed network meta-analysis to find the most effective modality for the differentiation between brain tumor recurrence and post-treatment radiation effects. METHODS: We conducted a comprehensive systematic search on PubMed and Embase. The quality of eligible studies was assessed using the Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) instrument. For each meta-analysis, we recalculated the effect size, sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio from the individual study data provided in the original meta-analysis using a random-effects model. Imaging technique comparisons were then assessed using NMA. Ranking was assessed using the multidimensional scaling approach and by visually assessing surface under the cumulative ranking curves. RESULTS: We identified 32 eligible studies. High confidence in the results was found in only one of them, with a substantial heterogeneity and small study effect in 21% and 9% of included meta-analysis respectively. Comparisons between MRS Cho/NAA, Cho/Cr, DWI, and DSC were most studied. Our analysis showed MRS (Cho/NAA) and 18F-DOPA PET displayed the highest sensitivity and negative likelihood ratios. 18-FET PET was ranked highest among the 17 studied techniques with statistical significance. APT MRI was the only non-nuclear imaging modality to rank higher than DSC, with statistical insignificance, however. CONCLUSION: The evidence regarding which imaging modality is best for the differentiation between radiation necrosis and post-treatment radiation effects is still inconclusive. Using NMA, our analysis ranked FET PET to be the best for such a task based on the available evidence. APT MRI showed promising results as a non-nuclear alternative.

Gigantic submandibular pleomorphic adenoma: A rare case report.

INTRODUCTION: Pleomorphic adenoma (PA) is the most common benign salivary gland tumor. When neglected on some occasions, its size and weight can enormously augment. CASE PRESENTATION: We report a case of a giant submandibular pleomorphic adenoma in a 75 years old female patient which measured 34 × 26 × 20 cm and weighed 8.1 kg. CONCLUSION: Neglecting such tumors without treatment, can cause severe facial disfigurement and can even hinder the airway.

Efficacy of Epidural Dexamethasone Combined with Intrathecal Nalbuphine in Lower Abdominal Oncology Operations.

BACKGROUND: Dragging pain during lower abdominal surgeries under intrathecal anesthesia is a common problem. Epidural steroid seemed to be effective in reducing intra and postoperative pain. Kappa receptor agonist like nalbuphine helps in reduction of visceral pain. Hence, this study was designed to detect the efficacy of epidural steroid dexamethasone with intrathecal Kappa opioid as a sole anesthetic technique in patients subjected to lower abdominal oncology operations. PATIENTS AND METHODS: Patients were randomly allocated into two groups; epidural placebo group-control group (Group P) - Intrathecal injection of 20 µg fentanyl followed by intrathecal injection of (15 mg) of hyperbaric bupivacaine 0.5%, then (epidural injection placebo 15 mL volume of sterile saline 0.9%). Epidural dexamethasone group-study group (Group D) - Intrathecal injection of 0.6 mg nalbuphine followed by intrathecal injection of (15 mg) of hyperbaric bupivacaine 0.5% then (epidural injection of 8 mg dexamethasone in 15 mL total volume using sterile saline 0.9%). RESULTS: Group D recorded significantly longer times to 1st analgesic request, sensory regression to S1 and modified bromage Score 0 with significant lower number of patients that had abdominal dragging pain in comparison with Group P. Visual analog score in the first four postoperative hours, total postoperative nalbuphine dose in 1st 24 h and incidence of nausea and vomiting were significantly lower in Group D. Heart rate and mean arterial pressure were comparable in both groups. Postoperative headache incidence was comparable in both groups. Both patient and surgeon satisfaction were significantly higher in Group D compared to Group P. CONCLUSION: Combined epidural dexamethasone with intrathecal nalbuphine as a sole anesthetic technique during lower abdominal oncology operations could be an efficient anesthetic technique that offered better block characteristics, with more analgesia and as a result it gained better patient and surgeon satisfaction.

Ultrasound-Guided Erector Spinae Plane Block Compared to Modified Pectoral Plane Block for Modified Radical Mastectomy Operations.

BACKGROUND: Modified radical mastectomy (MRM) is the most common surgery for cancer breast that is associated with marked postoperative pain. Effective control of this pain suppresses the surgical stress response and decreases the opioids and general anesthetics' needs. This study compared the erector spinae plane (ESP) block and the pectoral plane (PECS) block effects on the opioid consumption postoperatively, stress response, fentanyl needs intraoperatively, pain scores, and incidence of complications in female patients subjected to MRM surgery. PATIENTS AND METHODS: Fifty patients were allocated randomly and divided into two groups. Forty-seven patients were included in the final analysis after exclusion. ESP block group (E group, n = 24) received 20 mL of 0.25% levobupivacaine plus 0.5 µ/kg dexmedetomidine that was injected in-between erector spinae muscle and transverse process. PECS block group (P group, n = 23) received 30 mL of 0.25% levobupivacaine plus 0.5 µg/kg dexmedetomidine divided into 10 mL that was injected between the two pectoralis muscles in the interfascial plane and the other was 20 mL injected between the serratus anterior and the pectoralis minor. RESULTS: Postoperative morphine consumption and stress hormone level in P group were significantly lower than E group. The pain scores and number of patients requested analgesic postoperatively showed significantly higher values in E group. Hemodynamic parameters, fentanyl needed intraoperatively and the incidence of postoperative complications recorded no significant difference between the two groups. CONCLUSION: The current study demonstrated that PECS block provides better quality of analgesia than ESP block in patients subjected to MRM operations.

Pressure-Controlled Ventilation with Volume Guarantee Compared to Volume-Controlled Ventilation with Equal Ratio in Obese Patients Undergoing Laparoscopic Hysterectomy.

BACKGROUND: Laparoscopic hysterectomy operations especially for obese patients necessitate Trendelenburg position and pneumoperitoneum with carbon dioxide, which could affect cardiac and pulmonary functions. The present study aimed to compare the impact of pressure-controlled ventilation with volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) with equal ratio ventilation (ERV), i.e., I: E ratio of 1:1 on hemodynamics, respiratory mechanics, and oxygenation. PATIENTS AND METHODS: Eighty females with body mass index (BMI) >30 kg/m2 and with physical status American Society of Anesthesiologists Classes I and II undergoing laparoscopic hysterectomy were allocated randomly to either PCV-VG (Group P) or VCV with ERV (Group V). The ventilation parameters, hemodynamics, and arterial blood gases (ABGs) analysis were recorded at four times: (T1): after the anesthetic induction while in supine position by 10 min, (T2 and T3): after the CO2 pneumoperitoneum and Trendelenburg positioning by 30 and 60 min, respectively, and (T4): after desufflation and resuming the supine position. RESULTS: The peak inspiratory pressure in Group P recorded significant lower values than in Group V while the dynamic compliance was greater significantly in Group P than in Group V. No significant differences were reported as regards the ABG analysis, oxygenation, and hemodynamic data between both groups. CONCLUSION: In obese females undergoing laparoscopic hysterectomy surgeries, PCV-VG was superior to VCV with ERV as it provided higher dynamic compliance and lower peak inspiratory pressure that could be preferable, especially in those patients in whom cardiopulmonary function could be more susceptible to impairment.

Preperitoneal postcesarean section bupivacaine analgesia: Comparison between dexamethasone and dexmedetomidine as adjuvants.

BACKGROUND: The peritoneal wound is frequently neglected during laparotomy. The preperitoneal local anesthetics and many adjuvants were effective for postcesarean analgesia. Analgesia may involve somatic and autonomic components. The preperitoneal bupivacaine and the promising adjuvants dexamethasone or dexmedetomidine were compared in this study. PATIENTS AND METHODS: Sixty patients subjected to a cesarean section (CS) under general anesthesia divided into two groups using a bolus of preperitoneal bupivacaine 0.7 mg/kg with either 1ug/kg dexmedetomidine (Group P) or 8 mg dexamethasone (Group D). The time to the first analgesic request was the primary outcome. RESULTS: There was a significantly prolonged time to the first analgesic request in the Group P than the Group D and less required preperitoneal injections in the Group P, also pain assessed by Numerical Rating Scale (NRS) was lower in the Group P than the Group D after 6 h postoperatively up to 24 h. CONCLUSIONS: Dexmedetomidine provided better analgesia than dexamethasone as an adjuvant to preperitoneal bupivacaine post-CS.

Tumescent mastectomy: the current indications and operative tips and tricks.

BACKGROUND: Tumescent mastectomy refers to usage of a mixture of lidocaine and epinephrine in a diluting saline solution that makes flaps firm and tense, thus minimizing systemic drugs toxicity and making surgery possible with minimal bleeding. This technique is very useful in elder women and those with American Society of Anesthesiologists; score III and IV. The objective was to establish an alternative safe technique to general anesthesia in some selected mastectomy patients. PATIENTS AND METHODS: Twenty candidate women for total mastectomy and axillary dissection were enrolled and consented to participate. After preparation, an anatomically directed infiltration was made under sedation, using a cocktail of lidocaine, bupivacaine, and epinephrine, followed after 20 minutes by the surgical incision and completion of mastectomy. All intraoperative and postoperative outcomes were recorded. RESULTS: Although 7 cases required added analgesic medications, no conversion for general anesthesia was recorded. Mean operative time was 81±15.8 minutes. Mean blood loss was 95.8±47.5 mL. There was no recorded intraoperative hemodynamic instability. Postoperative visual analog score was not exceeding 4 till the end of the first 24 hours. Opioids were not required in any case, and the mean dosage of Ketorolac used was 30±8.75 mg. Drains output and the incidence of postoperative complications were acceptable. CONCLUSION: We can consider tumescent mastectomy in well-selected patients a safe alternative for performing mastectomy when general anesthesia is hazardous, with minimal blood loss and long lasting postoperative analgesia without an additive effect on the operative time, hospital stay, and intraoperative and postoperative complications.