Analgesic potential of transdermal nicotine patch in surgery: a systematic review and meta-analysis of randomised placebo-controlled trials.

OBJECTIVES: We aimed (1) to systematically review the efficacy of transdermal nicotine patches (NP) for postoperative analgesia, (2) to establish the current quality of evidence and assist clinical decision-making on the subject, and (3) to identify methodological limitations and the need for more well-designed studies. MATERIALS AND METHODS: We searched six electronic databases, protocol records, and other sources without date or language restriction until March 2022. To develop the search strategy, we formulated a clinical question by using the PICOD method. Eligibility criteria included randomised placebo-controlled trials on the analgesic potential of NP for surgical procedures. This systematic review followed the PRISMA 2020 statement, and we registered the protocol in PROSPERO (#CRD42020205956). RESULTS: We included 10 randomised placebo-controlled trials (535 patients). The NP administered before induction of anaesthesia and at beginning of surgery reduced the pain immediately after surgery (-0.38; 95% confidence interval [CI]: -0.73 to -0.02), and 6 h (-0.34; 95% CI: -0.68 to -0.01), 12 h (-0.43; 95% CI: -0.71 to -0.15) and 24 h (-0.35; 95%CI: -0.59 to -0.10) after surgery, compared with the placebo patch (PP) group. Sensitivity testing suggests that opioid use could underestimate NP analgesia. Late demand for the first analgesic and consumption of rescue analgesics tended to be lower in the NP group. CONCLUSIONS: The current findings suggest, with low certainty of evidence, the analgesic potential of NP for surgical procedures. CLINICAL RELEVANCE: Perioperative use of NP significantly improved postoperative pain, even when opioids were administered or prescribed. Nevertheless, the clinical relevance should be interpreted with caution, owing to the effect sizes of the summary measures and methodological issues. The analgesic potential of NP as an adjuvant therapy to regulate pain and acute inflammation may offer certain clinical advantages, thus warranting further investigation.

Magnetic Localization of Breast Lesions: A Large-Scale European Evaluation in a National Cancer Institute.

INTRODUCTION: For decades the standard for preoperative breast lesions' localization has been wire localization. In recent years the options for nonwired localization have significantly expanded and include radioactive seeds, radar reflectors, radiofrequency identification tags and magnetic seeds. The aim of our study is to evaluate on a large scale the performance of preoperative magnetic seed localization of nonpalpable breast lesions. MATERIAL AND METHODS: We prospectively collected data on all patients undergoing image-guided magnetic seed localization from September 2019 to December 2022. We analyzed imaging findings, histological results, and type of surgery. The primary outcome was the successful localization rate. Secondary outcomes were the successful placement rate, the ease of percutaneous positioning, the procedural complications, and the reintervention rate. RESULTS: A total of 1123 magnetic seeds were placed in 1084 patients by 4 radiologists under ultrasound (1053) or stereotactic (70) guidance. All seeds were detectable transcutaneously in all breasts sizes and at all depths by 7 surgeons with a success rate of 100%. A total of 97.5% seeds were correctly placed into the target lesions (only 2.5% were dislocated). All radiologists have shown good compliance during the procedure, and there were no complications or safety issues. The reoperation rate was 5.1%. CONCLUSIONS: Image-guided localization with magnetic seeds is an easy, safe, reliable, and effective method for localizing nonpalpable breast lesions. Both radiologists and surgeons agreed that the technology was intuitive to use and that it can be widely applied in preoperative localization in breast units.

Early preoperative progressive pneumoperitoneum for a symptomatic giant abdominal incisional hernia.

INTRODUCTION AND IMPORTANCE: Early preoperative progressive pneumoperitoneum (PPP) is a technique that helps large eventrations with loss of domain to reintroduce protruded organs. However, a standardized technique has not been developed. This technique has been proved in elective patients, but the evidence is scarce in patients with a high risk of incarceration/strangulation. CLINICAL FINDINGS AND INVESTIGATIONS: We present a 61-year-old patient with history of a thoracoabdominal aneurysm repair, developed a massive incisional hernia with loss of domain. At admission, he presented with abdominal pain and inability to reduce the hernia by himself, however it reduced after clinical examination. Aortic syndromes were excluded. INTERVENTIONS AND OUTCOME: After a multidisciplinary meeting, early PPP was initially performed. Later he was taken to surgery and admitted in the ICU to prevent abdominal hypertension. Medical complications resolved within 14 days. The patient did not report long-term complications. RELEVANCE AND IMPACT: PPP is a technique that pursues the prevention of abdominal hypertension syndrome in patients with large hernias with loss of domain electively. For patients with high risk of hernia complications, the evidence is limited regarding the applicability of early PPP. A multidisciplinary team can improve decision making and therefore reduce the risk of long-term complications. We show a case where PPP was performed in an acute painful, reducible hernia with a high risk of incarceration, showing that this approach can be an option for acutely ill patients.

Preoperative localisation of nonpalpable breast lesions using magnetic markers in a tertiary cancer centre.

BACKGROUND: We retrospectively evaluated safety and performance of magnetic seed localisation of nonpalpable breast lesions. METHODS: We reviewed records of patients with nonpalpable breast lesions preoperative localised by placing magnetic Magseed® marker between February 2019 and December 2020. During surgery, Sentimag® magnetic probe was used to localise the marker and guide surgery. Safety, lesion identification and excision with tumour with free margins and re-excision rate were assessed. RESULTS: A total of 77 Magseed® devices were placed into the breasts of 73 patients, 44 under ultrasound and 33 under stereotactic guidance (4 bilateral). All devices were retrieved as were the target lesions. Magnetic marker placement was successful in all cases without any adverse event. Intraoperative identification and excision of the localised lesion were successful in 77 of 77 of cases (100%). In three cases (all of them calcifications with the seed placed under stereotactic guidance), the seed did not reach the exact target position of the biopsy clip; thus, larger excision was needed, with localisation failure attributed to incorrect clip insertion (n = 1) or to clip dislocation (n = 2). Migration of the marker was negligible in all patients. Complete excision after the initial procedure with at least 1-mm disease-free margins was obtained in 74 out of 77 (96.1%) lesions. The re-excision rate was 3 out of 77 (4%). CONCLUSIONS: Magnetic marker localisation for nonpalpable breast lesions was safe, reliable, and effective in terms of lesion identification, excision with tumour-free margins and re-excision rate.

Diagnostic Performance of a Sonographic Volume and Solid Vascular Tissue Score (VSVTS) for Preoperative Risk Assessment of Pediatric and Adolescent Adnexal Masses.

STUDY OBJECTIVE: To evaluate the diagnostic performance of a Volume and Solid Vascular Tissue Score (VSVTS) for preoperative risk assessment of pediatric and adolescent adnexal masses. DESIGN: A retrospective cohort study comprised of all female individuals who presented with an adnexal mass that was managed surgically between April 2011 and March 2016. SETTING: The Hospital for Sick Children (Toronto, Ontario, Canada). PARTICIPANTS: Female individuals 1-18 years of age who presented to a large tertiary pediatric hospital with an adnexal mass that was managed surgically. MAIN OUTCOME MEASURES: Main outcome measures included diagnostic performance of the VSVTS for malignancy via sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR-), and receiver operating characteristic area-under-the-curve (AUC) analysis. RESULTS: A total of 179 masses in 169 subjects were included. The malignancy rate was 10.6%. The AUC for the VSTVS was 0.919. A VSTVS cut-off value of 4 achieved a sensitivity of 79% (95% CI 0.54-0.93), specificity of 88% (95% CI 0.82-0.93), PPV of 0.44 (95% CI 0.33-0.56), NPV of 0.97 (95% CI 0.94-0.99), LR+ of 6.77 (95% CI 4.18-10.97), and LR- of 0.24 (95% CI 0.10-0.57). CONCLUSIONS: A sonographic scoring system based on the volume and presence of solid vascular tissue improves PPV for preoperative risk stratification of adnexal masses in the pediatric and adolescent population compared to existing ultrasound-only approaches. Further prospective research is needed to determine how best to incorporate components of such scoring systems into clinical management algorithms.

Value of preoperative HE4 as predictor of advanced disease in endometrioid endometrial cancer.

OBJECTIVE: To explore the predictive value of serum human epididymis protein 4 (HE4) marker in the preoperative prediction of the risk of advanced disease in the endometrioid subtype of endometrial cancer, and its association with poor prognostic factors. In addition, a cut-off value of HE4 was defined to classify patients according to these results. METHODS: Prospective and multicenter cohort analytical pilot study of patients operated for endometrial cancer at the Miguel Servet University Hospital of Zaragoza (Spain) and the Complejo Universitario of León (Spain) from January 2017 to May 2019. Preoperative serum levels of HE4 were analyzed by clinical and pathologic characteristics. RESULTS: In all, 126 patients were included. A statistically significant association was found between the preoperative HE4 value and node involvement (P = 0.008), late-stage disease (P = 0.003), high histologic grade (P = 0.007), deep myometrial invasion (P = 0.001), lymphovascular space invasion (P = 0.001), and other pathologic factors. In addition, an HE4 cut-off value (156.4 pmol/L) has been determined to predict, preoperatively, which patients will present with early stage disease. CONCLUSIONS: The preoperative marker HE4 is a useful tool in the preoperative study of patients with endometrial cancer as it relates to late-stage disease as well as other prognostic factors in the endometrioid subtype of endometrial cancer.

The Role of Magnetic Resonance Imaging in the Pre-operative Evaluation of Women Diagnosed With Atypical Endometrial Hyperplasia.

BACKGROUND/AIM: To evaluate the role of MRI in patients with atypical endometrial hyperplasia (AEH) and incorporate MRI findings in predictive models estimating the risk of co-existent endometrial cancer (EC). PATIENTS AND METHODS: Data from 189 women diagnosed with AEH and had MRI scan prior to operation, over nine years, were retrospectively collected. RESULTS: Histology showed EC in 51 (27%) cases. Presence of myometrial invasion on MRI was more commonly detected in patients with EC compared to those with benign pathology (37.3% versus 10.9%, p<0.001). The sensitivity and specificity of MRI in identifying cancer were 37% and 89%, respectively. Age, menopausal status and presence of invasion on MRI were the best predictors for the presence of malignancy. CONCLUSION: Myometrial invasion on MRI is associated with increased risk of EC in women with AEH. Its accuracy in detecting malignancy improves when combined with clinical parameters. This could be of value for conservative-management candidates.

HE4 tumor marker as a predictive factor for lymphatic metastasis in endometrial cancer.

Endometrial cancer is the most common genital cancer in high-resource countries. Treatment is essentially surgical, but the role of lymphadenectomy in the treatment of low-stage and low-grade tumors has not been defined. Although no tumor factors have been validated for use as preoperative prognostic markers of endometrial cancer at yet, human epididymis protein 4 (HE4) has received much interest as a potential diagnostic and prognostic tumor marker. Since 2008, several studies have explored its utility in the management of endometrial cancer: HE4 may be a useful preoperative prognostic marker because it is associated with lymphatic metastasis and other unfavorable factors in endometrial cancer. In addition, some studies have explored a HE4 cutoff value to classify patients according to lymph node involvement. HE4 might be beneficial as a serum marker that helps clinicians in the decision-making algorithm for treatment of endometrial cancer, enabling them to perform individualized operations and decrease the adverse effects of unnecessary surgery.

[Flexion and extension osteotomy of the knee]. / Flexions- und Extensionsosteotomien am Kniegelenk.

OBJECTIVES: Flexion and extension osteotomy of the knee for symptomatic malalignment in the sagittal plane. INDICATIONS: Congenital/posttraumatic bony deficiencies in flexion/pathologic hyperextension in the knee. Additional treatment for ligament reconstruction. CONTRAINDICATIONS: Absolute: Infection, critical soft tissue situation, circulatory disorders. Relative: Osteoporosis, heavy smoker, obesity, reduced patient compliance. SURGICAL TECHNIQUE: Diagnostic arthroscopy of the knee. If the malposition is located at the proximal tibia, an extending or flexing high tibial osteotomy with correction of the tibial slope is carried out. If the malalignment is referred to the distal femur, the adjustment is performed by a distal femoral osteotomy. POSTOPERATIVE MANAGEMENT: Partial weight bearing with 20 kg for the first 6 postoperative weeks. Due to the tuberositas tibiae osteotomy, it is necessary to restrict the movement of the knee for the first 6 weeks. RESULTS: Between 2015 and 2016, 11 patients (2 female, 9 male) were treated with a flexion or extension osteotomy of the knee. Of these patients, 2 had symptomatic hyperflexion, 7 had restriction of movement with an exaggerated tibial slope, and 2 patients had an extension deficiency according to a malalignment of the distal femur. After surgery, the symptomatic pathologic movement of the knee was improved in every patient. One patient had pseudarthrosis during the healing process, which required a second operation with reosteosynthesis and bony grafting. These results are also reflected in an improvement of the preoperative IKDC score from 52.7 (range 37-82) to 1 year postoperative 75.8 (range 67-84). The Lysholm score increased from preoperative 40.2 (range 15-73) to postoperative 84.3 (range 68-91).

Dosimetric evaluation of Tomotherapy and four-box field conformal radiotherapy in locally advanced rectal cancer.

PURPOSE: To report the results of dosimetric comparison between intensity-modulated radiotherapy (IMRT) using Tomotherapy and four-box field conformal radiotherapy (CRT) for pelvic irradiation of locally advanced rectal cancer. MATERIALS AND METHODS: Twelve patients with locally advanced rectal cancer who received a short course preoperative chemoradiotherapy (25 Gy in 5 fractions) on the pelvis using Tomotherapy, between July 2010 and December 2010, were selected. Using their simulation computed tomography scans, Tomotherapy and four-box field CRT plans with the same dose schedule were evaluated, and dosimetric parameters of the two plans were compared. For the comparison of target coverage, we analyzed the mean dose, Vn Gy, Dmin, Dmax, radical dose homogeneity index (rDHI), and radiation conformity index (RCI). For the comparison of organs at risk (OAR), we analyzed the mean dose. RESULTS: Tomotherapy showed a significantly higher mean target dose than four-box field CRT (p = 0.001). But, V26.25 Gy and V27.5 Gywere not significantly different between the two modalities. Tomotherapy showed higher Dmax and lower Dmin. The Tomotherapy plan had a lower rDHI than four-box field CRT (p = 0.000). Tomotherapy showed better RCI than four-box field CRT (p = 0.007). For OAR, the mean irradiated dose was significantly lower in Tomotherapy than four-box field CRT. CONCLUSION: In locally advanced rectal cancer, Tomotherapy delivers a higher conformal radiation dose to the target and reduces the irradiated dose to OAR than four-box field CRT.

Clinical utility of fine needle aspiration cytology in pediatric parotid tumors.

OBJECTIVE: The purpose of this study was to evaluate the usefulness and accuracy of fine needle aspiration cytology (FNAC) in the diagnosis of pediatric parotid tumors. METHODS: From June 2002 to June 2012, 22 patients ≤18-years-of-age with parotid mass were treated at Chonnam National University Hospital. Included in the study were 21 cases with preoperative FNAC. A retrospective chart review analyzed the results of FNAC and compared them with the corresponding histopathological diagnosis. RESULTS: Twenty-one of the 22 patients had undergone preoperative FNAC, which diagnosed pleomorphic adenoma in 13 patients. The remaining eight patients were diagnosed with benign tumor (n = 6), malignant tumor (n = 1) or Kimura disease (n = 1). All 21 patients underwent parotid tumor removal. FNAC had a diagnostic sensitivity of 92.3%, positive-predictive value of 92.3% and accuracy of 90.5% for diagnosing pleomorphic adenoma of pediatric parotid tumor. FNAC had a diagnostic sensitivity of 100%, a positive-predictive value of 85% and accuracy of 85.7% for diagnosing benign parotid tumor. CONCLUSIONS: Preoperative FNAC is a useful and accurate adjunct for preoperative evaluation of pediatric parotid tumors. We recommend that preoperative FNAC should be part of the initial evaluation of pediatric patients with parotid masses.

Dosimetric evaluation of Tomotherapy and four-box field conformal radiotherapy in locally advanced rectal cancer

PURPOSE: To report the results of dosimetric comparison between intensity-modulated radiotherapy (IMRT) using Tomotherapy and four-box field conformal radiotherapy (CRT) for pelvic irradiation of locally advanced rectal cancer. MATERIALS AND METHODS: Twelve patients with locally advanced rectal cancer who received a short course preoperative chemoradiotherapy (25 Gy in 5 fractions) on the pelvis using Tomotherapy, between July 2010 and December 2010, were selected. Using their simulation computed tomography scans, Tomotherapy and four-box field CRT plans with the same dose schedule were evaluated, and dosimetric parameters of the two plans were compared. For the comparison of target coverage, we analyzed the mean dose, V(n Gy), D(min), D(max), radical dose homogeneity index (rDHI), and radiation conformity index (RCI). For the comparison of organs at risk (OAR), we analyzed the mean dose. RESULTS: Tomotherapy showed a significantly higher mean target dose than four-box field CRT (p = 0.001). But, V(26.25 Gy) and V(27.5 Gy) were not significantly different between the two modalities. Tomotherapy showed higher D(max) and lower D(min). The Tomotherapy plan had a lower rDHI than four-box field CRT (p = 0.000). Tomotherapy showed better RCI than four-box field CRT (p = 0.007). For OAR, the mean irradiated dose was significantly lower in Tomotherapy than four-box field CRT. CONCLUSION: In locally advanced rectal cancer, Tomotherapy delivers a higher conformal radiation dose to the target and reduces the irradiated dose to OAR than four-box field CRT.