Liposomal bupivacaine versus conventional anesthetic or placebo for hemorrhoidectomy: a systematic review and meta-analysis.

BACKGROUND: Liposome bupivacaine (LB) is a long-acting anesthetic to enhance postoperative analgesia. Studies evaluating the efficacy of the LB against an active comparator (bupivacaine or placebo) on acute postoperative pain control in hemorrhoidectomy procedures are few and heterogeneous. Therefore, we performed a systematic review and meta-analysis comparing LB's analgesic efficacy and side effects to conventional/placebo anesthetic in hemorrhoidectomy patients. METHODS: We performed a systematic review and meta-analysis of randomised controlled trials investigating the use of LB after haemorrhoidectomy. We searched the literature published from the time of inception of the datasets to August 19, 2022. The electronic databases included English publications in Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, and Scopus. RESULTS: A total of 338 patients who underwent a hemorrhoidectomy procedure enrolled in three randomized clinical trials were included. The overall mean age was 45.84 years (SD ± 11.43), and there was a male predominance (53.55% male). In total 194 patients (52.2%) received LB and 144 (47.8%) received either bupivacaine or placebo. Pain scores at 72 h in the LB (199, 266, and 300 mg) were significantly lower than in the bupivacaine HCl group (p = 0.002). Compared to the bupivacaine/placebo group, the time to first use of opioids in the LB group was significantly longer at LB 199 mg (11 h vs. 9 h), LB 266 mg (19 h vs. 9 h), and LB 300 mg (19 h vs. 8 h) (p < 0.05). Moreover, compared to the bupivacaine/epinephrine group, it was significantly lower in the LB 266 mg group (3.7 vs. 10.2 mg) and at LB 300 mg (13 vs. 33 mg) (p < 0.05). Finally, regarding adverse effects, the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups (OR 2.60, 95% CI 1.31-5.16). CONCLUSIONS: Comparing LB to conventional anesthetic/placebo anesthetic for hemorrhoidectomy, we found a statistically significant reduction in pain through 72 h, decreased opioid requirements, and delayed time to first opioid use. Moreover, the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups.

The impact of tumor location on long-term survival outcomes in patients with right-sided colon cancer.

BACKGROUND: The oncologic outcomes of right-sided cancers are generally grouped in studies. We hypothesized that tumor location (cecal vs. ascending vs. hepatic flexure) may influence cancer-specific outcomes. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients over 18 with non-metastatic, invasive (American Joint Committee on Cancer stage I-III) right-sided adenocarcinoma of the colon from 1988 to 2014 who underwent partial colectomy. Patients were categorized into groups: (1) cecum (2) ascending colon (3) hepatic flexure. Demographic, clinical and pathologic factors were compared between groups. Disease-specific and overall survival were described using the Kaplan-Meier method and compared using the log-rank test. Multivariate Cox regression analysis determined the independent association of primary tumor location. RESULTS: We identified 167,450 patients. Mean age was 72.2 ± 12.3 years and 54.9% were female. Of these, 81,611, 66,857, and 18,982 had cecal, ascending colon, and hepatic flexure cancers, respectively. Cecal cancers were associated with a lower number of examined nodes but a higher likelihood of nodal positivity. Cecal cancer patients were significantly older, had larger tumors, and higher tumor stage. On univariate analysis, cecal cancers were associated with poorer disease-specific and overall survival (all p values < 0.001). On multivariate analysis controlling for sex, age, tumor size, number of examined nodes and stage, hepatic flexure cancers were associated with worse disease-specific (HR 1.05) and overall survival (HR 1.03). CONCLUSION: Hepatic flexure cancers are associated with worse survival compared to more proximal colon cancers. The cause is likely multifactorial, including biological and technical factors. More aggressive surgical and multimodal therapy may be considered for hepatic flexure colon cancers.

Quality of total mesorectal excision and depth of circumferential resection margin in rectal cancer: a matched comparison of the first 20 robotic cases.

AIM: There are concerns about the impact of robotic proctectomy on the quality of total mesorectal excision (TME) and the impact of laparoscopic proctectomy on the depth of the circumferential resection margin (CRM). The aim of this study was to compare the first 20 consecutive robotic proctectomies performed in our unit with matched series of open and laparoscopic proctocolectomy performed by the same surgeon. METHOD: Data on the first 20 consecutive patients treated with robotic proctectomy for rectal cancer, <12 cm from the anal verge, by the senior author (RB) were extracted from a prospectively maintained database. Groups of patients treated with open and laparoscopic proctectomy, matched for age, gender and body mass index (BMI) with those undergoing robotic proctectomy, were selected. The quality of the TME was judged as complete, nearly complete or incomplete. CRM clearance was reported in millimetres. Physiological parameters and operative severity were assessed. RESULTS: Age (P = 0.619), Physiological and Operative Severity Score for the Enumeration of Morbidity and Mortality (POSSUM) score (P = 0.657), operative severity score (P = 0.977), predicted mortality (P = 0.758), comorbidities (P = 0.427), previous abdominal surgery (P = 0.941), tumour height (P = 0.912), location (P = 0.876), stage (P = 0.984), neoadjuvant chemoradiation (P = 0.625), operating time (P = 0.066), blood loss (P = 0.356), ileostomy (P = 0.934), conversion (P = 0.362), resection type (P = 1.000), flatus (P = 0.437), diet (P = 0.439), length of hospital stay (P = 0.978), complications (P = 0.671), reoperations (P = 0.804), reinterventions (P = 0.612), readmissions (P = 0.349), tumour size (P = 0.542; P = 0.532; P = 0.238), distal margin (P = 0.790), nodes harvested (P = 0.338) and pathology stage (P = 0.623) did not differ among the three groups. The quality of TME showed a trend to be lower following robotic surgery, although this was not statistically significant [open 95/5/15 (complete/nearly complete/incompete) vs laparoscopic 95/5/15 vs robotic 80/5/15; P = 0.235], but the degree of clearance at the CRM was significantly greater in robotic patients [open 8 (0-30) mm vs laparoscopic 4 (0-30) mm vs robotic 10.5 (1-30) mm; P = 0.02]. CONCLUSION: The study reports no statistically significant difference between open and laparoscopic techniques in the quality of TME during the learning curve of robotic proctectomy for rectal cancer and demonstrates an improved CRM.