The efficacy of single-dose postoperative intravenous dexamethasone for pain relief after endoscopic submucosal dissection for gastric neoplasm

Painkiller administration after endoscopic submucosal dissection surgery: a retrospective real-world study

OBJECTIVES

This study aimed to investigate the frequency of analgesic administration within 48 h after endoscopic submucosal dissection (ESD) or its derivative techniques across different segments of the digestive tract, as well as the timing of the initial analgesic administration.

MATERIALS AND METHODS

This retrospective observational study was built upon previous research. The primary outcomes assessed were the time to initial analgesic administration postoperatively and the frequency of analgesic use within 48 h after ESD surgery. Additionally, factors influencing painkiller administration in ESD patients were analyzed.

RESULTS

Of the 2162 patients included in the study, 570 (26.36%) required postoperative analgesic medications. Most patients required their initial analgesic within 8 h following ESD, with the highest demand observed within 2 h. Multivariate Cox regression analysis indicated that intraoperative administration of ketorolac reduced the likelihood of analgesic administration within 2 h postoperatively (hazard ratio [HR] = 0.35, 95% confidence interval [CI]: 0.15-0.79, p = 0.012). The time to first analgesic administration did not differ significantly among patients with varying surgical sites (H = 2.043, p = 0.843) or surgical methods (H = 8.647, p = 0.071). Similarly, no significant difference was observed in the frequency of analgesic use within 48 h across different surgical sites (H = 3.817, p = 0.576). However, patients who underwent endoscopic submucosal excavation (ESE) surgery exhibited a lower frequency of analgesic use compared to those who underwent endoscopic full-thickness resection (EFR) surgery (p = 0.038).

CONCLUSIONS

A subset of patients undergoing ESD exhibited a need for analgesics within the initial 48-hour postoperative period. Clinicians should carefully assess patients' pain needs and implement appropriate pain relief measures to improve postoperative outcomes.

TRIAL REGISTRATION

Chinese Clinical Trial Registry; ChiCTR2300072854.

Dexmedetomidine as an Adjunctive Sedative in Patients Undergoing Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

Introduction

Endoscopic submucosal dissection (ESD) is a technique for removing dysplastic lesions in the gastrointestinal tract but carries risks like pain and perforation. Dexmedetomidine, an α2-receptor agonist, offers potential benefits as an adjunct sedative during ESD by providing anxiolysis and analgesia. This systematic review and meta-analysis assesses its efficacy and safety.

Methodology

We searched databases including Embase, Medline/PubMed, Scopus, and Web of Science up to April 21, 2024, following PRISMA guidelines. Eligible studies used dexmedetomidine with other sedatives for ESD. We analyzed outcomes such as en-bloc and complete resection rates, sedation duration, and adverse events, using RevMan for meta-analysis with a random-effects model.

Results

The initial search retrieved 216 studies and after screening, eight studies were included in the final analysis. Dexmedetomidine showed no significant difference in en-bloc or complete resection rates compared to controls. Sedation and procedure times were similar between the two groups as well. Dexmedetomidine significantly reduced restlessness (OR 0.15, 95% CI:0.07 to 0.29) and increased bradycardia (OR 7.15, 95% CI 3.17 to 16.11) compared to controls. Upon subgroup analysis, Dexmedetomidine plus Propofol, and Dexmedetomidine plus Midazolam, revealed the same findings regarding restlessness and bradycardia compared to controls which confirmed the adjunctive effects of Dexmedetomidine.

Conclusion

Dexmedetomidine as an adjunctive sedative appears safe and effective in ESD, reducing restlessness without significant adverse events. The risk of bradycardia is increased, which may be reflective of reduced physiological stress. Future studies should explore optimal dosing and compare Dexmedetomidine with other sedatives in diverse populations.

Efficacy of alternate mucosa-submucosa clip closure in preventing postoperative adverse events for patients with gastric mucosal lesions after endoscopic submucosal dissection: a multicenter retrospective study

BACKGROUND

Endoscopic submucosal dissection (ESD) is the first-line treatment for gastric mucosal lesions. The artificial ulcers caused by ESD can lead to bleeding, perforation, and other adverse events.

OBJECTIVES

This study aimed to evaluate the efficacy of alternate mucosa-submucosa clip in preventing adverse events following ESD for gastric mucosal lesions.

DESIGN

Multicenter retrospective observational study.

METHODS

Data from 924 patients who underwent ESD for gastric mucosal lesions were retrospectively collected and categorized into completely closed and unclosed groups based on postoperative wound management. The incidence of adverse events and postoperative wound healing rate at 1 and 3 months were compared between the groups, and the factors related to delayed bleeding after ESD were analyzed.

RESULTS

The rate of delayed hemorrhage was lower in the completely closed group than in the unclosed group (0.8% vs 7.6%; p < 0.001), and subgroup analysis showed that this effect was consistent across all subgroups. The postoperative abdominal pain score was lower in the completely closed group than in the unclosed group (0 vs 2, p < 0.001). One month postoperatively, the wound healing rate was higher in the completely closed group (77.6% vs 55.1%; p < 0.001). Multivariable analysis showed that the presence of ulcers or scars on the lesion surface, and lesions located in the lower one-third of the stomach were risk factors for postoperative bleeding.

CONCLUSION

Application of alternate mucosa-submucosa clip closing the wound of ESD reduced the risk of postoperative bleeding, alleviated postoperative abdominal pain, and promoted artificial wound healing.

Dexmedetomidine as an Adjunctive Sedative in Patients Undergoing Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

Introduction

Endoscopic submucosal dissection (ESD) allows for curative en-bloc resection of dysplastic gastrointestinal (GI) tract lesions. However, it is associated with postoperative adverse events (AEs) such as pain, bleeding, and perforation. Dexmedetomidine, an α2-receptor agonist, has emerged as a promising adjunct sedative for ESD under moderate sedation, offering anxiolysis and analgesia. We conducted a systematic review and meta-analysis to evaluate its efficacy and safety for use in ESD.

Methods

A comprehensive systematic search was conducted across multiple databases, including Embase, Medline, Scopus, and Web of Science. Studies that involved ESD utilizing dexmedetomidine as an adjunctive medication in combination with other sedatives, were included. Data extraction and risk of bias assessment were independently performed by two reviewers. Meta-analysis was carried out with RevMan using a random-effects model.

Results

Eight studies were included in the final analysis. Dexmedetomidine showed no significant difference in en-bloc or complete resection rates compared to controls. Sedation and procedure times were similar between the two groups as well. Dexmedetomidine significantly reduced restlessness (OR 0.15, 95% CI:0.07 to 0.29) and increased bradycardia (OR 7.15, 95% CI 3.17 to 16.11) compared to controls. Upon subgroup analysis, Dexmedetomidine plus Propofol, and Dexmedetomidine plus Midazolam, revealed the same findings regarding restlessness and bradycardia compared to controls which confirmed the adjunctive effects of Dexmedetomidine.

Conclusions

Dexmedetomidine as an adjunctive sedative appears safe and effective in ESD, reducing restlessness without significant adverse events. The risk of bradycardia is increased, which may be reflective of reduced physiological stress. Future studies should explore optimal dosing and compare Dexmedetomidine with other sedatives in diverse populations.

Associations between Clinicopathological Characteristics and Intraoperative Opioid Requirements during Endoscopic Submucosal Dissection with Monitored Anesthesia Care: A Retrospective Study

Background and study aims: Endoscopic submucosal dissection is used to treat early gastric neoplasms. Compared with other endoscopic procedures, it requires higher doses of opioids, leading to adverse events during monitored anesthesia care. We investigated the correlations between clinicopathological characteristics and intraprocedural opioid requirements in patients who underwent endoscopic submucosal dissection under monitored anesthesia care. Patients and methods: The medical records of patients who underwent endoscopic submucosal dissection under monitored anesthesia care were retrospectively reviewed. The dependent variable was the total dose of fentanyl administered during the dissection, while independent variables were patient demographics, the American Society of Anesthesiologists physical status classification, preoperative vital sign data, and the pathological characteristics of the neoplasm. Correlations between variables were examined using multiple regression analysis. Results: The study included 743 patients. The median total fentanyl dose was 100 mcg. Younger age (coefficient -1.37; 95% confidence interval [CI] -1.78 to -0.95), male sex (16.12; 95% CI 6.99-25.24), baseline diastolic blood pressure (0.44; 95% CI 0.04-0.85), neoplasm length (1.63; 95% CI 0.90-2.36), and fibrosis (28.59; 95% CI 17.77-39.42) were positively correlated with the total fentanyl dose. Total fentanyl dose was higher in the differentiated (16.37; 95% CI 6.40-26.35) and undifferentiated cancers group (32.53; 95% CI 16.95-48.11) than in the dysplasia group; no significant differences were observed among the others. The mid-anterior wall (22.69; 95% CI 1.25-44.13), mid-posterior wall (29.65; 95% CI 14.39-44.91), mid-greater curvature (28.77; 95% CI 8.56-48.98), and upper groups (30.06; 95% CI 5.01-55.12) had higher total fentanyl doses than the lower group, whereas doses did not significantly differ for the mid-lesser curvature group. Conclusions: We identified variables that influenced opioid requirements during monitored anesthesia care for endoscopic submucosal dissection. These may help predict the needed opioid doses and identify factors affecting intraprocedural opioid requirements.

Intraoperative Dexmedetomidine Decreases Postoperative Pain after Gastric Endoscopic Submucosal Dissection: A Prospective Randomized Controlled Trial

BACKGROUND

Postoperative pain is one of the most common complications after gastric endoscopic submucosal dissection (ESD); however, there have been only a few studies assessing the efficacy of interventions on postoperative pain after gastric ESD. This prospective randomized controlled trial was designed to assess the effect of intraoperative dexmedetomidine (DEX) on postoperative pain after gastric ESD.

MATERIALS AND METHODS

A total of 60 patients undergoing elective gastric ESD under general anesthesia were randomly divided into the DEX group receiving DEX with a loading dose of 1 μg/kg, followed by a maintenance dose of 0.6 μg/kg/h until 30 min before the end of the endoscopic procedure, and the control group receiving normal saline. The primary outcome was the visual analog scale (VAS) score of postoperative pain. Secondary outcomes were the dosage of morphine for postoperative pain control, hemodynamic changes during the observable period, the occurrence of adverse events, lengths of postanesthesia care unit (PACU) and hospital stays, and patient satisfaction.

RESULTS

The incidence of postoperative moderate to severe pain was 27% and 53% in the DEX and control groups, respectively, with a significant difference. Compared to the control group, VAS pain scores at 1 h, 2 h, and 4 h postoperatively, the dosage of morphine in the PACU, and the total dosage of morphine within 24 h postoperatively were significantly decreased in the DEX group. Both incidences of hypotension and use of ephedrine in the DEX group were significantly decreased during surgery, but they were significantly increased in the postoperative period. Postoperative nausea and vomiting scores were decreased in the DEX group; however, the length of PACU stay, patient satisfaction, and duration of hospital stay were not significantly different between groups.

CONCLUSION

Intraoperative DEX can significantly decrease postoperative pain level, with a slightly reduced dosage of morphine and a decreased severity of postoperative nausea and vomiting after gastric ESD.

Efficacy of dexmedetomidine on postoperative pain in patients undergoing gastric and esophageal endoscopic submucosal dissection: a study protocol for a randomized controlled prospective trial

BACKGROUND

Endoscopic submucosal dissection (ESD) is widely used as an effective treatment of early gastric and esophageal tumors, as it is minimally invasive, safe, and convenient. Epigastric pain is a common complication of ESD. In the traditional cognition, the postoperative pain of ESD is not serious and does not attach too much attention. However, previous studies found that the incidence of moderate to severe pain after ESD can be as high as 44.9~62.8%. At present, there is no unified understanding of how to carry out good postoperative analgesia in patients undergoing ESD of stomach and esophagus. The purpose of present study is to investigate the efficacy of intraoperative dexmedetomidine (DEX) using on postoperative pain though observing the postoperative visual analog scale (VAS) score within 48 h after ESD surgery, so as to explore an effective analgesia and anesthetic method in patients undergoing gastric and esophagus ESD.

METHODS/DESIGN

This study is a prospective, single-center, two-arm, randomized control trail. In total, 120 patients undergoing endoscopic submucosal dissection were stratified by type of surgery (i.e., gastric or esophagus ESD) and randomized into two treatment groups, DEX group (group D, n = 60) and control group (group C, n = 60). Patients in the experimental group (DEX group) will be administrated a loading dose of DEX at 1 μg/kg for 15 min and a continuous infusion at 0.6 μg/kg/h until 30 min before the end of operation. In control group, the same volume of normal saline was infused. The primary outcome is VAS at 2 h after ESD surgery. The secondary outcome will be VAS at 1 h, 4 h, 6 h,18 h, 24 h, and 48 h, the status of perioperative hemodynamics, the use of remedial analgesics, sedation score, shivering, postoperative nausea and vomiting (PONV), and satisfaction scores of patient and complication of ESD (such as bleeding, perforation, aspiration pneumonia).

DISCUSSION

The results of this study will demonstrate that intraoperative application of DEX is beneficial for postoperative pain treatment in patients undergoing ESD. This study will not only confirm that postoperative pain treatment is necessary for patients undergoing ESD but also provides an effective anesthesia method for postoperative analgesia.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ID: ChiCTR2100043837 , registered on March 4, 2021, http://www.chictr.org.cn .

Efficacy of submucosal bupivacaine injection for pain relief after endoscopic submucosal dissection: A multicenter, prospective, randomized controlled, and double-blind trial

BACKGROUND AND AIM

Although abdominal pain is a common adverse event related to endoscopic submucosal dissection (ESD), it can be sometimes underestimated by endoscopists. There are some endoscopic interventions available for the prevention of post-ESD pain, but their efficacy has not been established. We investigated whether a submucosal injection of bupivacaine (BP) can reduce procedure-related abdominal pain compared with the standard method.

METHODS

We performed a multicenter, double-blinded, randomized controlled trial of 86 adult patients referred for ESD as treatment for gastric neoplasms. Patients were randomly assigned to either the BP submucosal or conventional solution group. Questionnaires were collected when the study began (baseline) and immediately after ESD, as well as at 6, 12, and 24 hours post-operatively. The primary outcome was indicated by the visual analog scale (VAS) evaluated at 6 hours after procedure.

RESULTS

There were no significant differences in primary outcomes between groups and among all time points (immediately, 12, and 24 hours after ESD). The VAS and short-form McGill pain (SF-MP) scores were higher immediately after ESD than at 6, 12, or 24 hours post-operatively. The incidence of abdominal pain immediately after ESD was 94.0% (78/83) for all patients of both groups, and there was no significant difference between the 2 groups in the rate of abdominal pain immediately after ESD (BP group 37/40 [92.5%] versus non-BP group 41/43 [95.3%], P = .934). In univariable and multivariable analyses, BP did not have protective effect on post-ESD abdominal pain.

CONCLUSIONS

Submucosal BP injection does not promote pain relief or mitigate the effects of post-ESD abdominal pain.

A Comparative Randomized Trial on the Optimal Timing of Dexamethasone for Pain Relief after Endoscopic Submucosal Dissection for Early Gastric Neoplasm

Background/Aims

The aim of this study was to compare the clinical effects of preoperative and postoperative dexamethasone on pain after endoscopic submucosal dissection (ESD) for early gastric neoplasm.

Methods

Forty patients with early gastric neoplasm who were scheduled for ESD were randomized into two groups according to the timing of steroid administration: preoperative (“pre”, n=20) and postoperative (“post”, n=20) steroid administration. The pre group received 0.15 mg/kg dexamethasone before ESD and placebo after, and the post group received pre-ESD placebo and post-ESD dexamethasone. The present pain intensity (PPI) index and the short-form McGill pain (SF-MP) questionnaire were evaluated.

Results

The primary outcome was PPI score at 6 hours after ESD. There was a greater reduction in 6-hour PPI in the pre group than in the post group (2.1±0.8 vs 3.0±1.1, respectively; p=0.006). The immediate PPI was also significantly lower in the pre group than in the post group (1.6±0.6 vs 2.9±0.6, respectively; p<0.001), and the total SF-MP scores were significantly lower in the pre group than in the post group both immediately and at 6 hours after the operation.

Conclusions

Preoperative administration of dexamethasone may produce a superior analgesic effect in patients who undergo ESD compared with the postoperative administration of dexamethasone.

Safety of Perioperative Glucocorticoids in Elective Noncardiac Surgery

Background

Glucocorticoids are increasingly used perioperatively, principally to prevent nausea and vomiting. Safety concerns focus on the potential for hyperglycemia and increased infection. The authors hypothesized that glucocorticoids predispose to such adverse outcomes in a dose-dependent fashion after elective noncardiac surgery.

Methods

The authors conducted a systematic literature search of the major medical databases from their inception to April 2016. Randomized glucocorticoid trials in adults specifically reporting on a safety outcome were included and meta-analyzed with Peto odds ratio method or the quality effects model. Subanalyses were performed according to a dexamethasone dose equivalent of low (less than 8 mg), medium (8 to 16 mg), and high (more than 16 mg). The primary endpoints of any wound infection and peak perioperative glucose concentrations were subject to meta-regression.

Results

Fifty-six trials from 18 countries were identified, predominantly assessing dexamethasone. Glucocorticoids did not impact on any wound infection (odds ratio, 0.8; 95% CI, 0.6 to 1.2) but did result in a clinically unimportant increase in peak perioperative glucose concentration (weighted mean difference, 20.0 mg/dl; CI, 11.4 to 28.6; P &lt; 0.001 or 1.1 mM; CI, 0.6 to 1.6). Glucocorticoids reduced peak postoperative C-reactive protein concentrations (weighted mean difference, −22.1 mg/l; CI, −31.7 to −12.5; P &lt; 0.001), but other adverse outcomes and length of stay were unchanged. No dose–effect relationships were apparent.

Conclusions

The evidence at present does not highlight any safety concerns with respect to the use of perioperative glucocorticoids and subsequent infection, hyperglycemia, or other adverse outcomes. Nevertheless, collated trials lacked sufficient surveillance and power to detect clinically important differences in complications such as wound infection.

Predictive Factors for Pain After Endoscopic Resection of Gastric Tumors

BACKGROUND

Abdominal pain is a common complaint following endoscopic resection (ER).

AIMS

To investigate the predictive factors for abdominal pain after ER.

METHODS

Patients who were scheduled to undergo endoscopic mucosal resection or endoscopic submucosal dissection for the treatment of gastric adenoma or cancer were prospectively enrolled. Pain scores were checked every 6 h after ER and whenever patients complained of pain by using a 0-10 pain scale. If the pain score exceeded 5, 25 mg of intravenous (IV) pethidine was administered.

RESULTS

Among 156 patients who underwent ER, 66 (42.3 %) received IV pethidine due to moderate/severe abdominal pain. Both the number of patients complaining of abdominal pain and the pain scores decreased with time following the procedure, with only a few patients complaining of mild abdominal pain 2 days after ER. Multivariate analysis showed that female sex [odds ratio (OR) 2.88; confidence interval (CI) 1.31-6.33], tumor location in the lower third of the stomach (OR 5.46; CI 2.31-12.92), and procedures time more than 60 min (OR 2.96; CI 1.26-6.98) were significant predictive factors for developing pain after ER.

CONCLUSIONS

Female sex, tumor location in the lower third of the stomach, and longer procedure time were significantly associated with pain after ER. Close monitoring and active management of pain is recommended for patients who have these risk factors. With these efforts, the majority of patients could experience pain relief within 2 days after the procedure.

Complications of endoscopic resection techniques for upper GI tract lesions

Adverse events can occur during and after the endoscopic resection of upper gastrointestinal lesions. Their incidence can be minimized through the adoption of preventive measures and their final outcomes can be optimized through prompt identification and adequate treatment. In this evidence-based review we describe the risk factors for adverse events, preventive measures to avoid them and their management when they occur. Algorithms of action are also provided. Oesophageal strictures can be prevented with corticosteroids (either locally injected or systemically administered) and treated with endoscopic dilatation. Bleeding can be minimized through the adoption of prophylactic coagulation and novel preventive measures are emerging and being evaluated. Bleeding management includes coagulation therapy, clips and haemostatic powders. Perforations can nowadays be successfully treated endoscopically in the majority of the cases and conservative treatment is associated with favourable outcomes although optimal management is unclear.

Efficacy of Intravenous Lidocaine During Endoscopic Submucosal Dissection for Gastric Neoplasm: A Randomized, Double-Blind, Controlled Study

Endoscopic submucosal dissection (ESD) is an advanced therapy for early gastric neoplasm and requires sedation with adequate analgesia. Lidocaine is a short-acting local anesthetic, and intravenous lidocaine has been shown to have analgesic efficacy in surgical settings. The aim of this study was to assess the effects of intravenous lidocaine on analgesic and sedative requirements for ESD and pain after ESD.Sixty-six patients scheduled for ESD randomly received either intravenous lidocaine as a bolus of 1.5 mg/kg before sedation, followed by continuous infusion at a rate of 2 mg/kg/h during sedation (lidocaine group; n = 33) or the same bolus and infusion volumes of normal saline (control group; n = 33). Sedation was achieved with propofol and fentanyl. The primary outcome was fentanyl requirement during ESD. We recorded hemodynamics and any events during ESD and evaluated post-ESD epigastric and throat pain.Fentanyl requirement during ESD reduced by 24% in the lidocaine group compared with the control group (105 ± 28 vs. 138 ± 37 μg, mean ± SD; P < 0.001). The lidocaine group reached sedation faster [40 (20-100) vs. 55 (30-120) s, median (range); P = 0.001], and incidence of patient movement during ESD decreased in the lidocaine group (3% vs. 26%, P = 0.026). Numerical rating scale for epigastric pain was significantly lower at 6 hours after ESD [2 (0-6) vs. 3 (0-8), median (range); P = 0.023] and incidence of throat pain was significantly lower in the lidocaine group (27% vs. 65%, P = 0.003). No adverse events associated with lidocaine were discovered.Administration of intravenous lidocaine reduced fentanyl requirement and decreased patient movement during ESD. Moreover, it alleviated epigastric and throat pain after ESD. Thus, we conclude that the use of intravenous adjuvant lidocaine is a new and safe sedative method during ESD.