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Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial (DREAMS Trial)

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1455 (Published 18 April 2017) Cite this as: BMJ 2017;357:j1455

Re: Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial (DREAMS Trial)

Dear Editor

It is good to see the DREAMS trial published. In summary it shows a short term benefit to patients receiving perioperative dexamethasone in terms of vomiting (up to 24 hours) and in antiemetic use (up to 72 hours). Importantly it showed no increase in post-operative infection or other complications. The authors note that such treatment may not be routine current practice and suggest it should be.

Dexamethasone is currently administered to more than half of patients undergoing surgery in the UK. There is currently much interest in whether anaesthetic technique has any impact on the risk of cancer recurrence [1] and this is an important reason why anaesthetists may decline to use dexamethasone as an antiemetic for colorectal cancer surgery. In a small retrospective analysis of only 43 patients undergoing colectomy, use of dexamethasone (by 20 patients) was associated with a statistically significant increase in metastatic recurrence of cancer after 5-yr follow-up [2]. This result was fragile - with only one altered outcome removing significance. Cancer related mortality was also increased but this result was not statistically significant. These results are concerning, but clearly not conclusive.

While dexamethasone provides short term symptomatic benefit to patients, the concern over more important longer term sequelae remains significant. The cohort of patients in the DREAMS study (and also in the similar PADDI Trial [3]) who underwent surgery for cancer resection represent an important cohort who's follow-up may provide important information, and which can be argued to be a moral responsibility. I am interested to know if the study group intend to follow up the study group longer term to examine any impact of cancer-related sequelae.

References
1Buggy DJ, Hemmings HC. Special issue on anaesthesia and cancer. British Journal of Anaestheisa 2014; 113 (suppl_1): i1-i3.
2 Singh PP, Lemanu DP, Taylor MHG, Hill AG. Association between preoperative glucocorticoids and long-term survival and cancer recurrence after colectomy: follow-up analysis of a previous randomized controlled trial. British Journal of Anaesthesia 113 (S1): i68–i73
3 Perioperative ADministration of Dexamethasone and Infection. https://www.paddi.org.au/ (Accessed 21 April 2017)

Competing interests: I am a collaborating author of the DREAMs study.

21 April 2017
Tim M Cook
Consultant in Anaesthesia and Intensive Care Medicine
Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundations Trust, Bath, UK
Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundations Trust, Bath, BA1 3NG
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