ABSTRACT
Pain management is a critical aspect of cancer treatment and palliative care, where pain can significantly impact quality of life. Chronic pain, which affects a significant number of people worldwide, remains a prevalent and challenging symptom for patients. While medications and psychosocial support systems play a role in pain management, surgical and radiological interventions, including cingulotomy, may be necessary for refractory cases. Cingulotomy, a neurosurgical procedure targeting the cingulate gyrus, aims to disrupt neural pathways associated with emotional processing and pain sensation, thereby reducing the affective component of pain. Although cingulotomy has shown promise in providing pain relief, particularly in patients refractory to traditional medical treatment, its use has declined in recent years due to advancements in non-destructive therapies and concerns about long-term efficacy and patient suitability. Modern stereotactic methods have enhanced the precision and safety of cingulotomy, reducing associated complications and mortality rates. Despite these advancements, questions remain regarding its long-term efficacy and suitability for patients with limited life expectancy, particularly those with cancer. A comprehensive systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, aimed at providing insights into the efficacy, potential benefits, and limitations of this neurosurgical procedure in managing intractable pain. An electronic search of PubMed, Embase, Scopus, and Web of Science was conducted with open database coverage dates. The review focused on outcomes such as pain intensity and quality of life. The inclusion criteria encompassed human studies of any age experiencing intractable cancer or non-cancer pain, with cingulotomy as the primary intervention. Various study designs were considered, including observational studies, clinical trials, and reviews focusing on pain and cingulotomy. Exclusion criteria included non-human studies, non-peer-reviewed articles, and studies unrelated to pain or cingulotomy. This review highlights the efficacy of stereotactic anterior cingulotomy in managing intractable pain, particularly when conventional treatments fail. Advanced MRI-guided techniques enhance precision, but challenges like cost and expertise persist. Studies included in this review showed significant pain relief with minimal adverse effects, although the optimal target remains debated. Neurocognitive risks exist, but outcomes are generally favorable. Expected adverse events include transient effects like urinary incontinence and confusion. Reoperation may be necessary for inadequate pain control, with a median pain relief duration of three months to a year. A double stereotactic cingulotomy appears to be safe and effective for refractory pain.
ABSTRACT
Background The coronavirus disease 2019 (COVID-19) pandemic provoked disruptions in healthcare delivery, leading to the cancellation and postponement of various health services, including surgery. Numerous countries closed their borders and established laws mandating the use of face masks and social distancing and enforced lockdowns, and various activities were constrained. Brazil, the largest and most populous country in Latin America, also experienced a rapid and sustained surge in infections and deaths. Brazil was the most severely impacted nation in Latin America. The impact of the pandemic on surgical services in Brazil has not been adequately studied since most studies only cover the early phases of the pandemic. Thus, this study aimed to assess the impact of the COVID-19 pandemic on surgical services throughout the entire period. Methods A retrospective cross-sectional design was used to examine surgical cases from 2019 to 2022 and compared the following indicators: (1) number of hospital admissions, (2) length of hospital stay (LOS) (in days), and (3) volume of urgent and elective procedures. Data was divided into four time periods, pre-pandemic (March-December 2019), pandemic (March-December 2020), recovery (March-December 2021), and post-pandemic (March-December 2022), and was analyzed for the number of admissions and LOS based on surgical procedures performed by stratifying according to region, sex, age, and type of surgery (urgent versus elective). Results The number of admissions for surgical procedures ranged between 859,646 and 4,015,624 for 2019, 686,616 and 3,419,234 for 2020, 787,791 and 3,829,019 for 2021, and 760,512 and 3,857,817 for 2022 for the category of region; 4,260,900 and 5,991,775 for 2019, 3,594,117 and 4,984,710 for 2020, 4,182,640 and 5,590,808 for 2021, and 4,077,651 and 5,561,928 for 2022 for the category of sex; and 2,170,288 and 3,186,117 for 2019, 1,516,830 and 2,825,189 for 2020, 1,748,202 and 3,030,272 for 2021, and 1,900,023 and 2,859,179 for 2022 for the category of age. The variable age showed a comparable trend, albeit with an expressive decline for surgeries in the age range of 0-19 years. The LOS (in days) for surgical procedures ranged between 110,157 and 910,846 for 2019, 58,562 and 897,734 for 2020, 67,926 and 904,137 for 2021, and 100,467 and 823,545 for 2022. Thoracic surgery indicated no statistically significant difference in the number of admissions and LOS. Elective surgeries had a decline in the number of admissions and LOS, a 13% and 9.3% decline between 2019 and 2020, respectively. Urgent surgeries experienced a slight decrease in admissions and LOS, with a decline of 2.4% and 2.8% between 2019 and 2020, respectively. Conclusions Population characteristics, such as age, sex, and region, showed decreased hospital admissions during the pandemic, followed by a recovery toward pre-pandemic levels afterward. The number of surgical admissions and the length of hospital stays decreased during the pandemic but gradually returned to pre-pandemic levels in the recovery and post-pandemic phases. Notably, thoracic surgery remained statistically consistent across all periods, indicating its emergency nature compared to other surgeries. Thus, we conclude that the pandemic had minimal impact on thoracic surgery cases, contributing to a stable trend.
