Kaique Flavio Xavier Cardoso Filardi

Background Opioid overdose still accounts for substantial deaths and hospitalizations in the United States. Opioids continue to be commonly prescribed for postoperative pain. Although variation in postoperative opioid prescribing has been previously described, contemporary national data using newly available discharge-prescribing variables may provide useful benchmarks across surgical specialties and procedures. We sought to describe current patterns of opioid prescribing at discharge across surgical specialties and high-volume procedures in the United States. Methods This cross-sectional analysis used the 2024 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and included adults undergoing selected procedures in the United States. The primary outcomes were the receipt of an opioid prescription at discharge and quantify the daily discharge opioid dose, expressed as morphine milligram equivalents per day (MME/day). Results Among 757,548 selected surgical procedures (mean [SD] age of patients, 56.35 [16.97] years; 441,799 [58.32%] female patients), 565,959 patients (74.71%) received an opioid prescription at discharge. Median daily opioid doses ranged from 30 to 45 MME/day across surgical specialties, and 4.1% of patients received a refill. Adjusted probabilities of receiving an opioid prescription at discharge varied by specialty: from 54.1% (95% CI 52.0%–55.9%) in cardiac surgery and 60.0% (95% CI 59.2%–60.7%) in vascular surgery to 84.3% (95% CI 84.1–84.5%) in orthopedics and 85.3% (95% CI, 84.7–85.9%) in thoracic surgery. Laparoscopic hernia repair, knee arthroplasty, hip arthroplasty, spine fusion, and laminectomy/corpectomy each had an adjusted probability of opioid prescription at discharge that exceeded 83%. Conclusions and relevance. This study provides an updated descriptive benchmark of postoperative opioid-prescribing patterns across surgical specialties and selected high-volume procedures. This evidence offers a foundation for strategic actions to reduce variation and improve patient care.

Purpose: Familial adenomatous polyposis is a hereditary condition that predisposes individuals to colorectal cancer. This study aimed to evaluate the efficacy and safety of pharmacological therapies for reducing polyp number, burden, and size in individuals with familial adenomatous polyposis.Methods: A systematic search was conducted in PubMed, Embase, Web of Science, and Cochrane. Randomized trials assessing the effects of pharmacological interventions on polyp number, polyp burden, and polyp size were included, and adverse events were also analyzed.Results: Sixteen studies (n=985) met the inclusion criteria. The mean participant age was 38±8.3 years, with a mean follow-up of 14.6±15.8 months. Of these studies, 62.5% focused on colorectal polyps, 18.8% on rectal polyps, 18.8% on duodenal polyps, and 12.5% addressed both colorectal and duodenal polyps. Pharmacological interventions were associated with a modest but statistically significant reduction in the number of polyps (Hedges g, −0.57; 95% confidence interval [CI], −1.08 to −0.05) and in average polyp size (Hedges g, −0.26; 95% CI, −0.49 to −0.04). However, no significant reduction in overall polyp burden was observed (Hedges g, −1.07; 95% CI, −2.21 to 0.06). In subgroup analyses, nonselective cyclooxygenase inhibitors produced a large reduction in polyp burden (Hedges g, −2.72; 95% CI, −3.28 to −2.16), while metformin also demonstrated benefit in a single study (Hedges g, −1.06; 95% CI, −1.86 to −0.27). Adverse events were generally infrequent and comparable to placebo. Conclusion: Chemopreventive interventions may reduce polyp number, burden, and size, and they appear to have a favorable safety profile.

Background: Barrett’s esophagus (BE) is described by the transformation of the normal squamous epithelium into metaplastic columnar epithelium, driven by chronic gastroesophageal reflux disease (GERD). BE is a recognized premalignant condition and the main precursor to esophageal adenocarcinoma (EAC). Understanding the molecular mechanisms underlying BE carcinogenesis is crucial for improving prevention, surveillance, and treatment strategies. Methods: This narrative review examines the molecular abnormalities associated with the progression of BE to EAC. Results: This study highlights inflammatory, genetic, epigenetic, and chromosomal alterations, emphasizing key pathways and biomarkers. BE progression follows a multistep process involving dysplasia and genetic alterations such as TP53 and CDKN2A (p16) mutations, chromosomal instability, and dysregulation of pathways like PI3K/AKT/mTOR. Epigenetic alterations, including aberrant microRNA expression or DNA methylation, further contribute to this progression. These molecular changes are stage-specific, with some alterations occurring early in BE during the transition to high-grade dysplasia or EAC. Innovations in chemoprevention, such as combining proton pump inhibitors and aspirin, and the potential of antireflux surgery to halt disease progression are promising. Incorporating molecular biomarkers into surveillance strategies and advancing precision medicine may enable earlier detection and personalized treatments. Conclusions: BE is the primary preneoplastic condition for EAC. A deeper understanding of its molecular transformation can enhance surveillance protocols, optimize the management of gastroesophageal reflux inflammation, and refine prevention and therapeutic strategies, ultimately contributing to a reduction in the global burden of EAC.

Effective postoperative pain management is essential to the patient’s recovery. The use of opioids as the primary line of pain treatment has been known to increase rates of length of stay, pulmonary complications, paralytic ileus, and nausea and vomiting. Therefore, guidelines strongly recommend alternative paths to reduce opioid consumption through multimodal analgesia, and the transversus abdominis plane block(USG-TAP) has been considered to be one of these optimistic alternatives. A comprehensive systematic search was conducted in four databases until April 2024. We only considered for this analysis randomized controlled trials that assessed the USG-TAP as part of multimodal anesthesia in patients undergoing laparoscopic bariatric surgery. Eleven studies comprising 789 patients were included in the meta-analysis. Our results showed a significant decrease in opioid consumption after the first 24 h of surgery (MD − 32.02 mg; 95% IC − 51.33, − 12.71; p < 0.01) and fewer patients required extra-dose of opioid (OR 0.20; 95% IC 0.07, 0.62; p < 0.01). The pain score showed to be also improved with the TAP block (MD − 0.69; 95% IC − 1.32, − 0.07; p = 0.03). No difference concerning time to deambulate, nausea and vomiting, and time of surgery was observed among the studies. This study reinforces the benefits of the use of USG-TAP block as part of multimodal analgesia in patients undergoing laparoscopic bariatric surgery.

Introduction: The potential benefit of intraoperative wound irrigation (IOWI) in preventing surgical site infection (SSI) remains unclear. The use of antimicrobial agents (AMA) or antiseptic agents (ASA) is controversial worldwide.Methods: We performed a systematic review and meta‐analysis of randomized clinical trials comparing AMA or ASA with saline solution in patients who underwent abdominal surgery. Sub‐analyses were performed on the type of surgery, type of intervention agent, and wound classification.Results: Nineteen studies comprising 4915 patients undergoing abdominal surgery were included. SSI was observed in 207 out of 2504 patients in the intervention group (8.26 %) and 344 out of 2411 patients in the control group (14.27%). Overall, intraoperative wound irrigation (IOWI) with AMA or ASA was associated with a lower SSI (Odds ratio (OR) 0.62; 95% CI 0.47, 0.82; p < 0.01; I² = 50%). Sub‐analyses have shown a tendency for decreased SSI in patients from emergency surgery (OR 0.46; 95% CI 0.30, 0.70; p < 0.01; I² = 23%), patients with contaminated wound (OR 0.48; 95% CI 0.31, 0.74; p < 0.01; I² = 24%), and either the use of AMA or ASA (OR 0.53 vs. 0.65).Conclusion: The overall use of AMA or ASA before skin closure was associated with decreased SSI. Lower rates of SSI were observed in the subgroup analysis. Furthermore, we must consider the critical heterogeneity of the studies.