Abstract Background The effect of regional analgesia on perioperative infectious complications remains unknown. We therefore tested the hypothesis that a composite of serious infections after colorectal surgery is less common in patients with regional analgesia than in those given Intravenous Patient-Controlled Analgesia (IV-PCA) with opiates. Methods Patients undergoing elective colorectal surgery lasting one hour or more under general anesthesia at the Cleveland Clinic Main Campus between 2009 and 2015 were included in this retrospective analysis. Exposures were defined as regional postoperative analgesia with epidurals or Transversus Abdominis Plane blocks (TAP); or IV-PCA with opiates only. The outcome was defined as a composite of in-hospital serious infections, including intraabdominal abscess, pelvic abscess, deep or organ-space Surgical Site Infection (SSI), clostridium difficile, pneumonia, or sepsis. Logistic regression model adjusted for the imbalanced potential confounding factors among the subset of matched surgeries was used to report the odds ratios along with 95% confidence limits. The significance criterion was p < 0.05. Results A total of 7811 patients met inclusion and exclusion criteria of which we successfully matched 681 regional anesthesia patients to 2862 IV-PCA only patients based on propensity scores derived from potential confounding factors. There were 82 (12%) in-hospital postoperative serious infections in the regional analgesia group vs. 285 (10%) in IV-PCA patients. Regional analgesia was not significantly associated with serious infection (odds ratio: 1.14; 95% Confidence Interval 0.87‒1.49; p-value = 0.339) after adjusting for surgical duration and volume of intraoperative crystalloids. Conclusion Regional analgesia should not be selected as postoperative analgesic technique to reduce infections.

Abstract Background: Laparoscopic surgical approaches enhance recovery, reduce postoperative pain, and shorten hospital length-of-stay. Nevertheless, increased intra-abdominal pressure is associated with decreased renal blood flow, renal hypoxia and acute kidney injury. When combined with Trendelenburg positioning, renal function may further deteriorate. We tested the primary hypothesis that the combination of laparoscopic surgical approach and Trendelenburg position is associated with larger reductions in estimated Glomerular Filtration Rate (eGFR) within the initial 48 postoperative hours compared to open surgery without Trendelenburg positioning. Secondarily, we tested, if laparoscopic procedures are associated with greater incidence of postoperative acute kidney injury. Methods: Adults who had laparoscopic colorectal surgery in Trendelenburg position at the Cleveland Clinic Main Campus from 2009 to 2016 were propensity-matched to patients who had comparable open procedures. Patients with pre-existing renal impairment were excluded. Results: Among 7,357 eligible patients, 1,846 laparoscopic cases with Trendelenburg were matched to 1,846 open cases. No association was found between laparoscopic approach and postoperative eGFR. A significant protective effect of the laparoscopic procedure on the odds of having AKI was found. Patients who had laparoscopic surgeries were an estimated 0.70 (95% CI 0.55, 0.90, pHolm-adj = 0.006) times as likely to have AKI as open surgical patients. Conclusion: Despite compelling potential mechanisms, laparoscopic approach with Trendelenburg position in adult colorectal surgeries did not worsen postoperative eGFR, and actually reduced postoperative acute kidney injury. Given the other advantages of laparoscopic surgery, the approach should not be avoided for concerns about renal injury.

Resumo Justificativa e objetivos: As flutuações dos hormônios sexuais femininos durante o ciclo menstrual influenciam a percepção da dor. A inibição endógena da dor é prejudicada na fase folicular do ciclo menstrual. Testamos a hipótese primária de que cirurgias em mulheres durante a fase folicular têm mais dor aguda e precisam de mais opioide do que aquelas na fase lútea e a hipótese secundária testada foi que as cirurgias em mulheres durante a fase folicular têm mais dor incisional aos três meses de pós-operatório. Métodos: No total, 127 mulheres adultas submetidas à colecistectomia laparoscópica foram randomizadas para serem operadas durante a fase lútea ou folicular de seus ciclos menstruais. Um regime padronizado para anestesia e tratamento da dor foi administrado a todas as pacientes. A dor e o consumo de analgésico foram avaliados na sala de recuperação pós-anestésica e a cada quatro horas nas primeiras 24 horas. Efeitos adversos foram avaliados a cada quatro horas. Os tempo para ingestão oral e deambulação foram registrados. Dor pós-cirúrgica, ansiedade hospitalar, escala de depressão e questionário SF-12 foram avaliados em visitas feitas no primeiro e terceiro meses. Resultados: Não houve diferença nos escores de dor aguda e no consumo de analgésicos durante o período de 24 horas, Escala Visual Analógica em 24 horas foi de 1,5 ± 1,5 cm para o grupo folicular e 1,4 ± 1,7 cm para o grupo lúteo (p = 0,57). A dor persistente no pós-operatório foi significativamente mais prevalente no primeiro e terceiro mês, com incidência de 33% e 32% nas pacientes em fase folicular versus 16% e 12% na fase lútea, respectivamente. A Escala Visual Analógica no primeiro e terceiro mês foi 1,6 ± 0,7 cm e 1,8 ± 0,8 cm no grupo folicular e 2,7 ± 1,3 cm e 2,9 ± 1,7 cm no grupo lúteo (p = 0,02), respectivamente. Não houve diferença significativa entre os grupos em relação à ansiedade e à depressão, escore SF-12 em ambos os tempos. Náusea foi mais comum no grupo na fase folicular (p = 0,01) e o tempo para alimentação oral foi menor na fase folicular (5,9 ± 0,9 horas) do que na fase lútea (6,8 ± 1,9 horas, p = 0,02). Conclusões: Embora a dor persistente no pós-operatório tenha sido significativamente mais prevalente no primeiro e no terceiro mês após a cirurgia, a magnitude da dor foi baixa. Nossos resultados não apoiam o agendamento de cirurgias tendo como alvo fases específicas do ciclo menstrual.

Abstract Background and objectives: Fluctuations of female sex hormones during menstrual cycle influence pain perception. Endogenous pain inhibition is impaired in follicular phase of menstrual cycle. We tested the primary hypothesis that the women having surgery during their follicular phase have more acute pain and require higher opioids than those in the luteal phase, and secondarily we tested that women who have surgery during their follicular phase have more incisional pain at 3 month postoperatively. Methods: 127 adult females having laparoscopic cholecystectomy were randomized to have surgery during the luteal or follicular phase of their menstrual cycle. Standardized anesthesia and pain management regimen was given to all patients. Pain and analgesic consumption were evaluated in post-anesthesia care unit and every 4 h in the first 24 h. Adverse effects were questioned every 4 h. Time to oral intake and ambulation were recorded. Post-surgical pain, hospital anxiety, depression scale, SF-12 questionnaire were evaluated at 1 and 3 month visits. Results: There was no difference in acute pain scores and analgesic consumption through the 24 h period, Visual Analog Scale at 24 h was 1.5 ± 1.5 cm for follicular group 1.4 ± 1.7 cm for luteal group (p = 0.57). Persistent postoperative pain was significantly more common one and at three month, with an incidence was 33% and 32% in the patients at follicular phase versus 16% and 12% at luteal phase, respectively. The Visual Analog Scale at one and at three month was 1.6 ± 0.7 cm and 1.8 ± 0.8 cm for follicular group and 2.7 ± 1.3 cm and 2.9 ± 1.7 cm in the luteal group (p = 0.02), respectively. There were no significant differences between the groups with respect to anxiety and depression, SF-12 scores at either time. Nausea was more common in follicular-phase group (p = 0.01) and oral feeding time was shorter in follicular phase (5.9 ± 0.9 h) than in luteal phase (6.8 ± 1.9 h, p = 0.02). Conclusions: Although persistent postoperative pain was significantly more common one and three months after surgery the magnitude of the pain was low. Our results do not support scheduling operations to target particular phases of the menstrual cycle.