-
Indian Journal of Otolaryngology and... Dec 2022Haemostasis during any surgical procedure is fundamental for attaining a positive patient outcome. Safe thyroid surgery requires meticulous attention for careful control...
Haemostasis during any surgical procedure is fundamental for attaining a positive patient outcome. Safe thyroid surgery requires meticulous attention for careful control of bleeding and safe guarding important structures like recurrent laryngeal nerve. Many methods such as ligation and suturing, electro ligation sealing, coagulation, and ultrasonic coagulation have been put to use for achieving haemostasis. The objective of this systemic review was to compare and review the surgical outcomes between harmonic (ultrasonic) scalpel and conventional ligature techniques in performing thyroid surgery. The systematic review was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and checklist with a total of 11 studies selected for qualitative analysis. The statistical software Review Manager 5.4.1 provided by the Cochrane Collaboration was used for performing the analysis on the two groups. It was concluded that the use of harmonic scalpel for thyroid surgery is useful for reducing operative time, postoperative pain, drainage volume and transient hypocalcemia, hence can be a reliable and a safe tool compared to conventional techniques often used for surgery.
PubMed: 36742765
DOI: 10.1007/s12070-021-03026-5 -
International Journal of Colorectal... Dec 2021Hemorrhoidectomy remains the gold standard treatment for grade III-IV hemorrhoids. However, despite strong recommendations for the suitability of outpatient surgery,... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Hemorrhoidectomy remains the gold standard treatment for grade III-IV hemorrhoids. However, despite strong recommendations for the suitability of outpatient surgery, post-operative pain has been a limitation to the widespread inclusion of this condition in day surgery programs. The aims of the study were to analyze and compare the post-operative pain of conventional open hemorrhoidectomy, considered the reference technique, against other surgical procedures such as closed hemorrhoidectomy, open hemorrhoidectomy using bipolar or ultrasonic sealant, hemorrhoidopexy, or HAL-RAR, when performed exclusively as outpatients.
METHODS
A systematic review and meta-analysis was conducted according to PRISMA methodology. All prospective and randomized studies of patients operated on for hemorrhoids in day surgery and specifying the value of post-operative pain, using a validated scale, were included. Conventional meta-analyses and a random-effects network meta-analysis were carried out.
RESULTS
Twenty-nine studies were included (3309 patients). None of the procedures described severe pain in the post-operative period. Hemorrhoidopexy was the least painful. Conventional open hemorrhoidectomy was the most painful on the first and seventh post-operative days. Pain was reduced after closed hemorrhoidectomy technique and when bipolar or harmonic scalpel was used. Furthermore, transfixive ligation of the hemorrhoidal pedicle was associated with increased post-operative pain.
CONCLUSION
Hemorrhoidal surgery is feasible in day surgery units and post-operative pain can be adequately managed in an outpatient setting. Hemorrhoidopexy was the least painful; however, data should be carefully evaluated by the high rate of long-term recurrence described in literature. Closed hemorrhoidectomy, performed with bipolar or ultrasonic sealing, avoiding transfixive ligation of the hemorrhoidal pedicle, may improve post-operative pain control.
TRIAL REGISTRATION
CRD42020185160.
Topics: Hemorrhoidectomy; Hemorrhoids; Humans; Network Meta-Analysis; Pain, Postoperative; Prospective Studies; Randomized Controlled Trials as Topic; Surgeons; Treatment Outcome
PubMed: 34417639
DOI: 10.1007/s00384-021-04013-6 -
Indian Journal of Cancer 2018Harmonic scalpel is considered as a promising surgical tool for breast cancer, while its advantage over conventional approach is still controversial. Therefore, we... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Harmonic scalpel is considered as a promising surgical tool for breast cancer, while its advantage over conventional approach is still controversial. Therefore, we performed this meta-analysis to compare the outcomes of harmonic scalpel and conventional tools in the surgery for breast cancer.
MATERIALS AND METHODS
Studies reporting the outcomes of harmonic scalpel and conventional technologies were systematically searched from online databases, PubMed and EMBASE up to April 30, 2018. Data were presented as odds ratio, risk ratio (RR), and mean difference (MD) with 95% confidence interval (CI).
RESULTS
Intraoperative blood loss (I = 96%, P < 0.05, MD = -68.78, 95% CI -93.31 to -44.24), seroma (I = 3%, P = 0.41, RR = 0.63, 95% CI 0.46-0.86) and hematoma formation (I = 0%, P = 0.64, RR = 0.41, 95% CI 0.23-0.73), drainage volume (I = 89%, P < 0.05, MD = -105.33, 95% CI -161.33 to -49.33) and time (I = 93%, P < 0.05, MD = -2.18, 95% CI -3.75 to -0.61), necrosis (I = 35%, P = 0.20, RR = 0.37, 95% CI 0.16-0.86), surgical duration (I = 79%, P < 0.05, MD = -8.49, 95% CI -16.56 to -0.43), and hospital stay (I = 97%, P < 0.05, MD = -0.94, 95% CI -1.74 to -0.14) are significantly different between the two groups.
CONCLUSIONS
Harmonic scalpel is superior to conventional tools in terms of decreasing intraoperative blood loss, seroma and hematoma formation, drainage volume and time, necrosis prevalence, surgical duration, and hospital stay, which should be strongly recommended in the surgery for breast cancer.
Topics: Blood Loss, Surgical; Breast Neoplasms; China; Drainage; Electrocoagulation; Female; Hematoma; Humans; Mastectomy, Modified Radical; Surgical Instruments
PubMed: 30829269
DOI: 10.4103/ijc.IJC_306_18 -
Clinical Rheumatology Mar 2020Optimal wound care is an essential component in the management of systemic sclerosis (SSc) digital ulcers (DUs). DU debridement has been suggested to reduce...
Optimal wound care is an essential component in the management of systemic sclerosis (SSc) digital ulcers (DUs). DU debridement has been suggested to reduce ulcer-related pain and improve tissue healing. However, only a minority of rheumatologists perform DU debridement, and there is no standard of care/protocol. Our objectives were to (i) evaluate the current evidence for the use of debridement in DU management and (ii) assess whether there are any specific protocols. A systematic literature review was performed searching the PubMed database (between 01/01/1950-01/03/2019) in accordance with PRISMA guidelines. Two independent reviewers screened and extracted the abstracts/full manuscripts. Articles in English, which focussed on SSc-DU debridement/curettage, were included. Exclusion criteria included studies of juvenile/paediatric patients and basic/non-clinical research. Our search identified 1497 studies of which 4 studies were included in our final analysis. Three studies used scalpel debridement, and one study used this in combination with autolytic debridement. No studies specifically reported the effect on DU healing from debridement. Autolytic debridement with hyaluronate-based products was associated with significant ulcer pain and inflammation. Local anaesthetic significantly reduces pain both during and after debridement. Combined local and oral analgesia is often required for more severe or infected DUs. DU (scalpel and autolytic) debridement is being used by some clinicians in rheumatology; however, there are no standardised protocols. To improve wound care for SSc-DUs, future research should focus on developing a standardised protocol for SSc-DU debridement, with a view to facilitate randomised controlled trials to demonstrate safety and treatment efficacy.Key Points• Optimal wound care is an essential component in the management of systemic sclerosis-digital ulcers.• 'Sharp' debridement uses a scalpel, whereas 'autolytic' debridement uses dressings to optimize endogenous tissue lysis.• There is significant variation in the use of digital ulcer debridement in systemic sclerosis.• A standardized protocol and randomized controlled trials are needed to demonstrate debridement the safety and efficacy of digital ulcer debridement in systemic sclerosis.
Topics: Anesthetics, Local; Debridement; Fingers; Humans; Pain; Pain Management; Scleroderma, Systemic; Skin Ulcer; Wound Healing
PubMed: 31955323
DOI: 10.1007/s10067-019-04924-4 -
International Journal of Surgery... Mar 2020To compare outcomes of diathermy and scalpel for skin incision in patients undergoing open inguinal hernia repair. (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVES
To compare outcomes of diathermy and scalpel for skin incision in patients undergoing open inguinal hernia repair.
METHODS
We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources to identify all randomised controlled trials (RCTs) and observational studies comparing use of diathermy and scalpel for skin incision in patients undergoing inguinal hernia repair. Surgical site infection (SSI) was the primary outcome measure. Secondary outcome measures included haematoma, seroma, visual analogue scale (VAS) pain score at 6 h, 12 h, and 24 h, and incision time. We used Cochrane risk of bias tool and ROBINS-I tool to assess the risk of bias of randomised and non-randomised studies. Fixed-effect model was applied to calculate pooled outcome data.
RESULTS
We identified 9 studies, 4 randomised controlled trials and 5 prospective cohort studies, enrolling a total of 830 patients. Meta-analysis of RCTs showed no difference between the diathermy and scalpel groups in terms of surgical site infection (OR: 0.77, 95% CI 0.34, 1.75, P = 0.53), seroma (OR: 0.86, 95% CI 0.29, 2.55, P = 0.78), VAS pain score at 6 h (MD: -0.10, 95% CI -0.31, 0.11, P = 0.34), 12 h (MD: -0.10, 95% CI -0.13, 0.33, P = 0.40), and 24 h (MD: 0.03, 95% CI -0.16, 0.21, P = 0.79). Use of diathermy for skin incision was associated with shorter incision time (MD: -36.00, 95% CI -47.92, -24.08, P < 0.00001) and lower risk of haematoma (OR: 0.14, 95% CI 0.03, 0.65, P = 0.01). Meta-analysis of observational studies showed no difference between the diathermy and scalpel groups in terms of surgical site infection (OR: 0.87, 95% CI 0.54, 1.39, P = 0.55), haematoma (OR 0.14, 95% CI 0.02-1.23, P = 0.08), seroma (OR: 0.86, 95% CI 0.29, 2.55, P = 0.78), VAS pain score at 6 h (MD: -0.10, 95% CI -0.44, 0.24, P = 0.56), 12 h (MD: -0.10, 95% CI -0.26, 0.46, P = 0.58), and 24 h (MD: 0.10, 95% CI -0.27, 0.47, P = 0.59). Use of diathermy for skin incision was associated with shorter incision time (MD: -39.40, 95% CI -41.02, -37.78, P < 0.00001). The results remained consistent through sensitivity analyses. The between-study heterogeneity was low and the quality of the available evidence was moderate.
CONCLUSIONS
There is no difference between use of diathermy and scalpel for skin incision in patients undergoing open inguinal hernia repair in terms of surgical site infection, seroma and postoperative pain. Use of diathermy for skin incision may be associated with shorter incision time and may reduce the risk of haematoma formation.
Topics: Diathermy; Hernia, Inguinal; Humans; Pain, Postoperative; Prospective Studies; Seroma; Surgical Instruments; Surgical Wound Infection
PubMed: 31978649
DOI: 10.1016/j.ijsu.2020.01.020 -
International Journal of Surgical... 2015The ultrasonic Harmonic scalpel has demonstrated clinical and surgical benefits in dissection and coagulation. To evaluate its use in gastrectomy, we conducted a... (Meta-Analysis)
Meta-Analysis Review
The ultrasonic Harmonic scalpel has demonstrated clinical and surgical benefits in dissection and coagulation. To evaluate its use in gastrectomy, we conducted a systematic review and meta-analysis of randomized controlled trials comparing the Harmonic scalpel to conventional techniques in gastrectomy for patients with gastric cancer. International databases were searched without language restrictions for comparisons in open or laparoscopic gastrectomy and lymphadenectomy. The meta-analysis used a random-effects model for all outcomes; continuous variables were analyzed for mean differences and dichotomous variables were analyzed for risk ratios. Sensitivity analyses were conducted for study quality, type of conventional technique, and imputation of study results. Ten studies (N = 935) met the inclusion criteria. Compared with conventional hemostatic techniques, the Harmonic scalpel demonstrated significant reductions in operating time (-27.5 min; P < 0.001), intraoperative blood loss (-93.2 mL; P < 0.001), and drainage volume (-138.8 mL; P < 0.001). Results were numerically higher for conventional techniques for hospital length of stay, complication risk, and transfusions but did not reach statistical significance. Results remained robust to sensitivity analyses. This meta-analysis demonstrates the clear advantages of using the Harmonic scalpel compared to conventional techniques, with improvements demonstrated across several outcome measures for patients undergoing gastrectomy and lymphadenectomy.
Topics: Adult; Aged; Aged, 80 and over; Blood Loss, Surgical; Blood Transfusion; Drainage; Female; Gastrectomy; Humans; Length of Stay; Lymph Node Excision; Male; Middle Aged; Operative Time; Postoperative Complications; Randomized Controlled Trials as Topic; Stomach Neoplasms; Treatment Outcome
PubMed: 26075090
DOI: 10.1155/2015/397260 -
Journal of Medical Economics Aug 2016Harmonic devices have become a world-wide standard for dissection and hemostasis in thyroidectomy. Numerous systematic reviews have reported superior operating times,... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Harmonic devices have become a world-wide standard for dissection and hemostasis in thyroidectomy. Numerous systematic reviews have reported superior operating times, blood loss, post-operative pain, length of stay, and overall safety outcomes. What has not been extensively evaluated in a robust manner is their economic impact. The purpose of this study is to evaluate the hospital costs associated with open thyroidectomy using Harmonic devices compared with conventional techniques for hemostasis.
METHODS
A systematic review of Medline, Scopus, and CENTRAL was performed from January 1, 2000 to May 23, 2014 without language restrictions for randomized clinical trials comparing Harmonic surgical devices to conventional methods in thyroidectomy. The main outcome measure was total reported costs. Costs were pooled using the ratio of means and a random effects model. Sensitivity analyses assessed whether differences in patient and trial characteristics, healthcare setting, or choice of statistical model affected outcomes.
RESULTS
Seven studies met the inclusion criteria. A total of 476 participants had procedures performed with Harmonic devices and 478 with conventional monopolar electrosurgery and clamp, cut and tie techniques. Compared with conventional techniques, Harmonic devices reduced total reported costs by 10% (p = 0.007), resulting in a $229 US dollars (USD) absolute reduction from mean baseline costs. Results remained relatively robust to additional sensitivity analyses.
CONCLUSIONS
This systematic review and meta-analysis demonstrates that the Harmonic family of surgical devices is associated with a reduction in total reported costs in thyroidectomy compared with conventional techniques. A large portion of the overall savings derives from a reduction in operative costs.
Topics: Blood Loss, Surgical; Hospital Costs; Humans; Length of Stay; Models, Econometric; Operating Rooms; Operative Time; Pain, Postoperative; Personnel Staffing and Scheduling; Randomized Controlled Trials as Topic; Surgical Instruments; Thyroidectomy
PubMed: 26999563
DOI: 10.3111/13696998.2016.1168826 -
The Cochrane Database of Systematic... May 2015Oral squamous cell carcinoma is the most common form of malignancy of the lip and oral cavity, often being proceeded by potentially malignant disorders (PMD). Early... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Oral squamous cell carcinoma is the most common form of malignancy of the lip and oral cavity, often being proceeded by potentially malignant disorders (PMD). Early detection can reduce the malignant transformation of PMD and can improve the survival rate for oral cancer. The current standard of scalpel biopsy with histology is painful for patients and involves a delay whilst histology is completed; other tests are available that are unobtrusive and provide immediate results.
PRIMARY OBJECTIVE
To estimate the diagnostic accuracy of index tests for the detection of oral cancer and PMD of the lip and oral cavity, in people presenting with clinically evident lesions.
SECONDARY OBJECTIVE
To estimate the relative accuracy of the different index tests.
SEARCH METHODS
The electronic databases were searched on 30 April 2013. We searched MEDLINE (OVID) (1946 to April 2013) and four other electronic databases (the Cochrane Diagnostic Test Accuracy Studies Register, the Cochrane Oral Health Group's Trials Register, EMBASE (OVID) and MEDION (Ovid)). There were no restrictions on language in the searches of the electronic databases. We conducted citation searches and screened reference lists of included studies for additional references.
SELECTION CRITERIA
We selected studies that reported the diagnostic test accuracy of the following index tests when used as an adjunct to conventional oral examination in detecting PMD or oral squamous cell carcinoma of the lip or oral cavity: vital staining, oral cytology, light-based detection and oral spectroscopy, blood or saliva analysis (which test for the presence of biomarkers in blood or saliva).
DATA COLLECTION AND ANALYSIS
Two review authors independently screened titles and abstracts for relevance. Eligibility, data extraction and quality assessment were carried out by at least two authors, independently and in duplicate. Studies were assessed for methodological quality using QUADAS-2. Meta-analysis was used to combine the results of studies for each index test using the bivariate approach to estimate the expected values of sensitivity and specificity.
MAIN RESULTS
We included 41 studies, recruiting 4002 participants, in this review. These studies evaluated the diagnostic accuracy of conventional oral examination with: vital staining (14 studies), oral cytology (13 studies), light-based detection or oral spectroscopy (13 studies). Six studies assessed two combined index tests. There were no eligible diagnostic accuracy studies evaluating blood or salivary sample analysis.The summary estimates for vital staining obtained from the meta-analysis were sensitivity of 0.84 (95% CI 0.74 to 0.90) with specificity of 0.70 (0.59 to 0.79), with 14 studies were included in the meta-analysis. For cytology, sensitivity was 0.91 (0.81 to 0.96) and specificity was 0.91 (0.81 to 0.95) with 12 studies included in the meta-analysis. For light-based detection, sensitivity was 0.91 (0.77 to 0.97) and specificity was 0.58 (0.22 to 0.87) with 11 studies included in the meta-analysis. The relative test accuracy was assessed by adding covariates to the bivariate analysis, no difference in model fit was observed.
AUTHORS' CONCLUSIONS
The overall quality of the included studies was poor. None of the adjunctive tests can be recommended as a replacement for the currently used standard of a scalpel biopsy and histological assessment. Given the relatively high values of the summary estimates of sensitivity and specificity for cytology, this would appear to offer the most potential. Combined adjunctive tests involving cytology warrant further investigation.
Topics: Biomarkers, Tumor; Carcinoma, Squamous Cell; Coloring Agents; Early Detection of Cancer; Humans; Light; Lip Neoplasms; Mouth Neoplasms; Saliva
PubMed: 26021841
DOI: 10.1002/14651858.CD010276.pub2 -
JAMA Otolaryngology-- Head & Neck... Apr 2020Several temperature-controlled surgical instruments (TCSIs) have been used in tonsillectomy. However, to our knowledge, a meta-analysis of the differences between modern... (Meta-Analysis)
Meta-Analysis
Adolescents and Adults Undergoing Temperature-Controlled Surgical Instruments vs Electrocautery in Tonsillectomy: A Systematic Review and Meta-analysis of Randomized Clinical Trials.
IMPORTANCE
Several temperature-controlled surgical instruments (TCSIs) have been used in tonsillectomy. However, to our knowledge, a meta-analysis of the differences between modern TCSIs and electrocautery (EC) has not been conducted.
OBJECTIVE
To compare TCSIs with EC with regard to the intraoperative and postoperative parameters of tonsillectomy.
DATA SOURCES
PubMed (MEDLINE), Embase, and the Cochrane Library were searched independently by 2 authors for relevant articles.
STUDY SELECTION
A literature search identified randomized clinical trials comparing the outcomes of TCSIs vs EC. The search keywords were harmonic scalpel, ultracision, PlasmaBlade, coblation, radiofrequency ablation, and tonsillectomy. Studies of adult and adolescent patients were included.
DATA EXTRACTION AND SYNTHESIS
Data from each study were extracted. A random-effects model was used in the pooled analysis.
MAIN OUTCOMES AND MEASURES
Four outcomes were analyzed: postoperative pain level on days 1, 2, 7, and 14 after surgery; postoperative bleeding; operative time; and intraoperative blood loss.
RESULTS
This meta-analysis included 11 studies with a total of 629 unique patients. (Mean ages ranged from 16 to 55 years.) The studies were further categorized by the methods of comparison. Five articles used between-participant comparisons, and 6 used within-participant comparisons (of the left vs right sides of the participant's body). The pooled results of the studies with between-participant measures showed that postoperative pain scores were lower in the TCSI group on the first day (standardized mean differences [SMD], -0.41 [95% CI, -0.77 to -0.06]) and seventh day (SMD, -0.76 [95% CI, -1.47 to -0.04]). The pooled results of the studies with within-participant measures showed that the postoperative pain scores were lower in the TCSI group on the first day (SMD, -0.37 [95% CI, -0.63 to -0.12]) and second day (SMD, -0.60 [95% CI, -1.10 to -0.10]). The pooled analysis of overall bleeding, major bleeding, minor bleeding, primary bleeding, and secondary bleeding in both the types of studies with between-participant measures and those with within-participant measures showed no significant differences between the TCSI and EC groups. Intraoperative blood loss and operative time were not significantly different between the groups.
CONCLUSIONS AND RELEVANCE
Compared with EC, TCSIs were associated with significantly reduced pain on the first day after tonsillectomy, per this meta-analysis. The rates of overall bleeding, primary bleeding, secondary bleeding, major bleeding, and minor bleeding between TCSIs and EC were comparable. Intraoperative blood loss and operative time also showed no significant intergroup differences. Surgeons may consider using these modern instruments according to personal experiences, preferences, and cost-effectiveness criteria.
Topics: Adolescent; Adult; Blood Loss, Surgical; Electrocoagulation; Humans; Operative Time; Pain, Postoperative; Postoperative Hemorrhage; Randomized Controlled Trials as Topic; Temperature; Tonsillectomy
PubMed: 32027341
DOI: 10.1001/jamaoto.2019.4605 -
HPB : the Official Journal of the... Feb 2020Major liver resection can lead to significant morbidity and mortality. Blood loss is one of the most important factors predicting a good outcome. Although various... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Major liver resection can lead to significant morbidity and mortality. Blood loss is one of the most important factors predicting a good outcome. Although various transection methods have been reported, there is no consensus on the best technique. This systematic review and network meta-analysis aims to characterise and identify the best reported technique for elective parenchymal liver transection based on published randomised controlled trials (RCT's).
METHODS
A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Central to identify RCT's up to 5th June 2019 that examined parenchymal transection for liver resection. Data including study characteristics and outcomes including intraoperative (blood loss, operating time) and postoperative measures (overall and major complications, bile leaks) were extracted. Indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analyses (NMA) which maintains randomisation within trials.
RESULTS
This study identified 22 RCT's involving 2360 patients reporting ten parenchymal transection techniques. Bipolar cautery has lower blood loss and shorter operating time than stapler (mean difference: 85 mL; 22min) and Tissue Link (mean difference: 66 mL; 29min). Bipolar cautery was ranked first for blood loss and operating time followed by stapler and TissueLink. Harmonic scalpel is associated with lower overall complications than Hydrojet (Odds ratio (OR): 0.48), BiClamp forceps (OR: 0.46) and clamp crushing (OR: 0.41).
CONCLUSION
Bipolar cautery techniques appear to best at reducing blood loss and associated with shortest operating time. In contrast, Harmonic scalpel appears best for overall and major complications. Given the paucity of data and selective outcome reporting, it is still hard to identify what is the best technique for liver resection. Therefore, further high-quality large-scale RCT's are still needed.
Topics: Blood Loss, Surgical; Cautery; Hepatectomy; Humans; Operative Time; Postoperative Complications; Randomized Controlled Trials as Topic
PubMed: 31668587
DOI: 10.1016/j.hpb.2019.09.014