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European Journal of Vascular and... Jan 2017The importance of antiplatelet therapy for the management and prevention of ischaemic stroke cannot be overstated. Despite the established guidelines, there is no clear... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The importance of antiplatelet therapy for the management and prevention of ischaemic stroke cannot be overstated. Despite the established guidelines, there is no clear consensus on how to manage antiplatelet therapy during and after carotid interventions.
OBJECTIVE
The objective was to undertake a systematic literature review and perform a meta-analysis to assess the effects of dual antiplatelet therapy in carotid endarterectomy (CEA) and stenting (CAS).
DATA SOURCES
Electronic information sources (MEDLINE, EMBASE, CINAHL, CENTRAL) and bibliographic reference lists were searched to identify randomised controlled trials (RCTs) and observational studies reporting comparative outcomes of dual versus single antiplatelet therapy in CEA and CAS.
METHODS
Primary outcomes were mortality and stroke within 30 days of intervention. Secondary outcomes were transient ischaemic attack (TIA), major bleeding, groin or neck haematoma, and myocardial infarction (MI). Dichotomous outcome measures were reported using the risk difference (RD) and 95% confidence interval (CI). Combined overall treatment effects were calculated using fixed-effect or random-effects models.
RESULTS
Three RCTs and seven observational studies were identified reporting a total of 36,881 CEAs and 150 CAS procedures. In CEA, there were no differences in stroke/TIA/death between single and dual antiplatelet therapy, but there was a significant risk of major bleeding (RD, 0.00; 95% CI, 0.00-0.01; p = .0003) and neck haematoma with dual therapy (RD, 0.04; 95% CI, 0.01-0.06; p = .001). In addition, the rate of MI was higher in the dual therapy group than the single therapy group (RD, 0.00; 95% CI, 0.00-0.01; p = .003). In CAS, there was no difference in major bleeding or haematoma formation, but a significant difference in TIA in favour of dual therapy was identified (RD -0.13, 95% CI, -0.22 to -0.05; p = .003).
CONCLUSIONS
Dual antiplatelet therapy demonstrates advantages over single therapy only in CAS, as indicated by a reduced risk of TIA. Dual antiplatelet therapy was associated with an increased risk of bleeding complications in patients undergoing CEA.
Topics: Drug Therapy, Combination; Endarterectomy, Carotid; Hematoma; Hemorrhage; Humans; Ischemic Attack, Transient; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Complications; Stents; Stroke
PubMed: 27894896
DOI: 10.1016/j.ejvs.2016.10.011 -
The British Journal of Surgery Aug 2023Anastomotic leak is one of the most feared complications of colorectal surgery, and probably linked to poor blood supply to the anastomotic site. Several technologies... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Anastomotic leak is one of the most feared complications of colorectal surgery, and probably linked to poor blood supply to the anastomotic site. Several technologies have been described for intraoperative assessment of bowel perfusion. This systematic review and meta-analysis aimed to evaluate the most frequently used bowel perfusion assessment modalities in elective colorectal procedures, and to assess their associated risk of anastomotic leak. Technologies included indocyanine green fluorescence angiography, diffuse reflectance spectroscopy, laser speckle contrast imaging, and hyperspectral imaging.
METHODS
The review was preregistered with PROSPERO (CRD42021297299). A comprehensive literature search was performed using Embase, MEDLINE, Cochrane Library, Scopus, and Web of Science. The final search was undertaken on 29 July 2022. Data were extracted by two reviewers and the MINORS criteria were applied to assess the risk of bias.
RESULTS
Some 66 eligible studies involving 11 560 participants were included. Indocyanine green fluorescence angiography was most used with 10 789 participants, followed by diffuse reflectance spectroscopy with 321, hyperspectral imaging with 265, and laser speckle contrast imaging with 185. In the meta-analysis, the total pooled effect of an intervention on anastomotic leak was 0.05 (95 per cent c.i. 0.04 to 0.07) in comparison with 0.10 (0.08 to 0.12) without. Use of indocyanine green fluorescence angiography, hyperspectral imaging, or laser speckle contrast imaging was associated with a significant reduction in anastomotic leak.
CONCLUSION
Bowel perfusion assessment reduced the incidence of anastomotic leak, with intraoperative indocyanine green fluorescence angiography, hyperspectral imaging, and laser speckle contrast imaging all demonstrating comparable results.
Topics: Humans; Anastomotic Leak; Indocyanine Green; Anastomosis, Surgical; Digestive System Surgical Procedures; Perfusion
PubMed: 37253021
DOI: 10.1093/bjs/znad154 -
Journal of Vascular Surgery Mar 2022Spinal cord ischemia (SCI) is one of the most devastating complications after descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) repairs. Patients who...
OBJECTIVE
Spinal cord ischemia (SCI) is one of the most devastating complications after descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) repairs. Patients who develop SCI have a poor prognosis, with mortality rates reaching 75% within the first year after surgery. Many factors have been shown to increase the risk of this complication, including the extent of TAA repair, length of aortic and collateral network coverage, embolization, and reduced spinal cord perfusion pressure. As a result, a variety of treatment strategies have been developed. We aimed to provide an up-to-date review of SCI rates with associated treatment algorithms from open and endovascular DTA and TAA repair.
METHODS
Using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, a literature review with the MeSH (medical subject headings) terms "spinal cord ischemia," "spinal cord ischemia prevention and mitigation strategies," "spinal cord ischemia rates," and "spinal cord infarction" was performed in the Cochrane and PubMed databases to find all peer-reviewed studies of DTA and TAA repair with SCI complications reported. The search was limited to 2012 to 2021 and English-language reports. MeSH subheadings, including diagnosis, complications, physiopathology, surgery, mortality, and therapy, were used to further restrict the included studies. Studies were excluded if they were not of humans, had not pertained to SCI after DTA or TAA operative repair, and if the study had primarily discussed neuromonitoring techniques. Additionally, studies with <40 patients or limited information regarding SCI protection strategies were excluded. Each study was individually reviewed by two of us (S.L. and A.D.) to assess the type and extent of aortic pathology, operative technique, SCI protection or mitigation strategies, rates of overall and permanent SCI symptoms, associations with SCI on multivariate analysis, and mortality.
RESULTS
Of the 450 studies returned by the MeSH search strategy, 41 met the inclusion criteria and were included in the final analysis. For the endovascular DTA repair patients, the overall SCI rates ranged from 0% to 10.6%, with permanent SCI symptoms ranging from 0% to 5.1%. The rate of overall SCI after endovascular and open TAA repair was 0% to 35%. The permanent SCI symptom rate was reported by only one study of open repair at 1.1%. The permanent SCI symptom rate after endovascular TAA repair was 2% to 20.5%.
CONCLUSIONS
The present review has provided an up-to-date review of the current rates of SCI and the prevention and mitigation strategies used during DTA and TAA repair. We found that a multimodal approach, including a bundled institutional protocol, staging of multiple repairs, preservation of the collateral blood flow network, augmented spinal cord perfusion, selective cerebrospinal fluid drainage, and distal aortic perfusion during open TAA repairs, appears to be important in reducing the risk of SCI.
Topics: Algorithms; Aorta, Thoracic; Aortic Diseases; Blood Vessel Prosthesis Implantation; Decision Support Techniques; Endovascular Procedures; Humans; Risk Assessment; Risk Factors; Spinal Cord Ischemia; Time Factors; Treatment Outcome
PubMed: 34740806
DOI: 10.1016/j.jvs.2021.10.039 -
The Cochrane Database of Systematic... Jun 2018For people with cystic fibrosis and advanced pulmonary damage, lung transplantation is an available and viable option. However, graft rejection is an important potential... (Review)
Review
BACKGROUND
For people with cystic fibrosis and advanced pulmonary damage, lung transplantation is an available and viable option. However, graft rejection is an important potential consequence after lung transplantation. Immunosuppressive therapy is needed to prevent episodes of graft rejection and thus subsequently reduce morbidity and mortality in this population. There are a number of classes of immunosuppressive drugs which act on different components of the immune system. There is considerable variability in the use of immunosuppressive agents after lung transplantation in cystic fibrosis. While much of the research in immunosuppressive drug therapy has focused on the general population of lung transplant recipients, little is known about the comparative effectiveness and safety of these agents in people with cystic fibrosis. This is an update of a previously published review.
OBJECTIVES
To assess the effects of individual drugs or combinations of drugs compared to placebo or other individual drugs or combinations of drugs in preventing rejection following lung transplantation in people with cystic fibrosis.
SEARCH METHODS
We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register and scanned references of the potentially eligible study. We also searched the www.clinicaltrials.gov registry and the World Health Organisation (WHO) International Clinical Trials Registry Platform (ICTRP) to obtain information on unpublished and ongoing studies.Date of latest search: 29 May 2018.
SELECTION CRITERIA
Randomised and quasi-randomised studies.
DATA COLLECTION AND ANALYSIS
We independently assessed the studies identified from our searches for inclusion in the review. Should eligible studies be identified and included in future updates of the review, we will independently extract data and assess the risk of bias. We will use GRADE to summarize our results through a summary of findings table for each comparison we present in the review.
MAIN RESULTS
While five studies addressed the interventions of interest, we did not include them in the review because the investigators of the studies did not report any information specific to people with cystic fibrosis. Our attempts to obtain this information have not yet been successful. We will include any provided data in future updates of the review.
AUTHORS' CONCLUSIONS
The lack of currently available evidence makes it impossible to draw conclusions about the comparative efficacy and safety of the various immunosuppressive drugs among people with cystic fibrosis after lung transplantation. A 2013 Cochrane Review comparing tacrolimus with cyclosporine in all lung transplant recipients (not restricted to those with cystic fibrosis) reported no significant difference in mortality and risk of acute rejection. However, tacrolimus use was associated with lower risk of broncholitis obliterans syndrome and arterial hypertension and higher risk of diabetes mellitus. It should be noted that this wider review contained only a small number of included studies (n = 3) with a high risk of bias. Additional randomised studies are required to provide evidence for the benefit and safety of the use of immunosuppressive therapy among people with cystic fibrosis after lung transplantation.
Topics: Cystic Fibrosis; Graft Rejection; Humans; Immunosuppressive Agents; Lung Transplantation
PubMed: 29921013
DOI: 10.1002/14651858.CD009421.pub4 -
Deutsches Arzteblatt International Aug 2016Besides cholecystectomy (CC), percutaneous cholecystostomy (PC) has been recommended for the management of critically ill patients with acute cholecystitis. However,... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Besides cholecystectomy (CC), percutaneous cholecystostomy (PC) has been recommended for the management of critically ill patients with acute cholecystitis. However, solid evidence on the benefit of PC in this subgroup of patients is lacking.
METHODS
In accordance with the PRISMA guidelines for systematic reviews, we systematically searched the Cochrane Library, CINAHL, MEDLINE, Embase, and Scopus for relevant studies published between 2000 and 2014. Two investigators independently screened the studies included.
RESULTS
Six studies with a total of 337 500 patients (PC 10 045, CC 327 455) were included for meta-analysis. Significant differences in favor of CC were recorded with regard to the rate of mortality (OR 4.28, [1.72 to 10.62], p = 0.0017), length of hospital stay (OR 1.41, [1.02 to 1.95], p = 0.04), and the rate of readmission for biliary complaints (OR 2.16, [1.72 to 2.73], p<0.0001). There was no statistically significant difference between both intervention arms with regard to complications (OR 0.74, [0.36 to 1.53], p = 0.42) and re-interventions (OR 7.69, [0.68 to 87.33], p = 0.10).
CONCLUSION
The benefit of percutaneous cholecystostomy (PC) over cholecystectomy (CC) in the management of critically ill patients with acute cholecystitis could not be proven in this systematic review.
Topics: Adult; Aged; Cholecystectomy; Cholecystitis, Acute; Cholecystostomy; Critical Illness; Evidence-Based Medicine; Female; Hospital Mortality; Humans; Incidence; Length of Stay; Male; Middle Aged; Patient Readmission; Postoperative Complications; Risk Factors; Survival Rate; Treatment Outcome
PubMed: 27598871
DOI: 10.3238/arztebl.2016.0545 -
BMC Gastroenterology Apr 2020Gastric decompression after pancreatic surgery has been a routine procedure for many years. However, this procedure has often been waived in non-pancreatic abdominal... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Gastric decompression after pancreatic surgery has been a routine procedure for many years. However, this procedure has often been waived in non-pancreatic abdominal surgeries. The aim of this meta-analysis was to determine the necessity of routine gastric decompression (RGD) following pancreatic surgery.
METHODS
PubMed, the Cochrane Library, EMBASE, and Web of Science were systematically searched to identify relevant studies comparing outcomes of RGD and no gastric decompression (NGD) after pancreatic surgery. The overall complications, major complications, mortality, delayed gastric emptying (DGE); clinically relevant DGE (CR-DGE), postoperative pancreatic fistula (POPF), clinically relevant POPF (CR-POPF), secondary gastric decompression, and the length of hospital stay were evaluated.
RESULTS
A total of six comparative studies with a total of 940 patients were included. There were no differences between RGD and NGD groups in terms of the overall complications (OR = 1.73, 95% CI: 0.60-5.00; p = 0.31), major complications (OR = 2.22, 95% CI: 1.00-4.91; p = 0.05), incidence of secondary gastric decompression (OR = 1.19, 95% CI: 0.60-2.02; p = 0.61), incidence of overall DGE (OR = 2.74; 95% CI: 0.88-8.56; p = 0.08; I = 88%), incidence of CR-POPF (OR = 1.28, 95% CI: 0.76-2.15; p = 0.36), and incidence of POPF (OR = 1.31, 95% CI: 0.81-2.14; p = 0.27). However, RGD was associated with a higher incidence of CR-DGE (OR = 5.45; 95% CI: 2.68-11.09; p < 0.001, I = 35%), a higher rate of mortality (OR = 1.53; 95% CI: 1.05-2.24; p = 0.03; I = 83%), and a longer length of hospital stay (WMD = 5.43, 95% CI: 0.30 to 10.56; p = 0.04; I = 93%).
CONCLUSIONS
Routine gastric decompression in patients after pancreatic surgery was not associated with a better recovery, and may be unnecessary after pancreatic surgery.
Topics: Decompression, Surgical; Gastrostomy; Humans; Intubation, Gastrointestinal; Pancreatectomy; Pancreaticoduodenectomy; Postoperative Complications; Stomach
PubMed: 32334515
DOI: 10.1186/s12876-020-01265-4 -
BMC Health Services Research Jun 2017Chronic low back pain is a common health problem for adult workers and causes an enormous economic burden. With the improvement of minimally invasive surgical techniques... (Review)
Review
BACKGROUND
Chronic low back pain is a common health problem for adult workers and causes an enormous economic burden. With the improvement of minimally invasive surgical techniques (MIS) in spinal fusion and the development of fusion devices, more lumbar operations are today being performed through a less invasive technique. When compared with open surgeries (OS), MIS has demonstrated better clinical outcomes including operation time, blood loss, complication rates and length of hospital stay. The aim of this review was to identify and summarize evidence on the time to return to work and the duration of post-operation narcotic use for patients who had lumbar spinal fusion operations using MIS and OS techniques.
METHODS
A systematic literature review was performed including studies identified from PubMed, EMBASE, the Cochrane Collaboration, and the Centre for Review and Dissemination (CRD) (January 2004–April 2014) for publications reporting on time to return to work and post-operation narcotic use after MIS or OS lumbar spinal fusion surgeries.
RESULTS
Out of a total of 36 included studies, 28 reported on the time to return to work and 17 on the narcotic use after MIS or OS. Four studies described the time to return to work directly comparing MIS and OS. Three studies, from the US, directly compared the duration of narcotic use between MIS- transforaminal lumbar interbody fusion (TLIF) and OS-TLIF. In addition to the time to return to work, 23 studies reported on the rate of return to work and the employment rate before and after surgery, and two Swedish studies presented sick leave data.
CONCLUSION
There is a gap of good quality data describing the time to return to work and narcotic use after lumbar spinal fusion operations using MIS or OS techniques. However, the current systematic literature review indicates that patients who have lumbar spinal fusion operations, with the MIS procedure, generally return to work after surgery more quickly and require less post-operation narcotics for pain control compared to patients who have OS.
Topics: Humans; Low Back Pain; Lumbar Vertebrae; Minimally Invasive Surgical Procedures; Narcotics; Randomized Controlled Trials as Topic; Return to Work; Spinal Fusion; Treatment Outcome
PubMed: 28655308
DOI: 10.1186/s12913-017-2398-6 -
BJS Open Feb 2019The use of peritoneal lavage to prevent postoperative intra-abdominal abscess (IAA) after appendicectomy has been debated widely. (Meta-Analysis)
Meta-Analysis
BACKGROUND
The use of peritoneal lavage to prevent postoperative intra-abdominal abscess (IAA) after appendicectomy has been debated widely.
METHODS
A systematic review and meta-analysis of suction alone lavage for appendicitis was performed to determine the relative benefit of lavage. Primary outcomes were postoperative IAA and wound infection (WI). Inclusion criteria were human studies reporting a comparison of appendicectomy with or without peritoneal lavage.
RESULTS
Eight studies met the inclusion criteria, the majority of which were retrospective. Only three were RCTs. Four studies included analysis only of the paediatric population. The rate of IAA was 1·0-19·5 per cent in patients receiving suction alone and 1·5-18·6 per cent in those having lavage. WI rates were 1·0-29·2 per cent for suction alone and 0·8-20·5 per cent for lavage. The pooled risk difference for IAA was 0·01 (95 per cent c.i. -0·03 to 0·06; = 0·50) and that for WI was 0·00 (-0·05 to 0·05; = 0·98). Analyses of both outcomes indicated a medium degree of heterogeneity between effect estimates with values of 71 per cent ( = 0·001) and 70 per cent ( = 0·010) for IAA and WI respectively.
CONCLUSION
There is no evidence of benefit of lavage over suction for postoperative infective complications, and no individual study demonstrated a significant benefit in patients receiving lavage.
Topics: Abdominal Abscess; Acute Disease; Appendectomy; Appendicitis; Humans; Intraoperative Care; Peritoneal Lavage; Postoperative Complications; Suction; Surgical Wound Infection
PubMed: 30734012
DOI: 10.1002/bjs5.50118 -
Acta Ophthalmologica Feb 2015Prophylactic treatment of retinal breaks has been examined in several studies and reviews, but so far, no studies have successfully applied a systematic approach. In the... (Review)
Review
Prophylactic treatment of retinal breaks has been examined in several studies and reviews, but so far, no studies have successfully applied a systematic approach. In the present systematic review, we examined the need of follow-up after posterior vitreous detachment (PVD) - diagnosed by slit-lamp biomicroscopy or Goldmann 3-mirror examination - with regard to retinal breaks as well as the indication of prophylactic treatment in asymptomatic and symptomatic breaks. A total of 2941 publications were identified with PubMed and Medline searches. Two manual search strategies were used for papers in English published before 2012. Four levels of screening identified 13 studies suitable for inclusion in this systematic review. No meta-analysis was conducted as no data suitable for statistical analysis were identified. In total, the initial examination after symptomatic PVD identified 85-95% of subsequent retinal breaks. Additional retinal breaks were only revealed at follow-up in patients where a full retinal examination was compromised at presentation by, for example, vitreous haemorrhage. Asymptomatic and symptomatic retinal breaks progressed to rhegmatogenous retinal detachment (RRD) in 0-13.8% and 35-47% of cases, respectively. The cumulated incidence of RRD despite prophylactic treatment was 2.1-8.8%. The findings in this review suggest that follow-up after symptomatic PVD is only necessary in cases of incomplete retinal examination at presentation. Prophylactic treatment of symptomatic retinal breaks must be considered, whereas no unequivocal conclusion could be reached with regard to prophylactic treatment of asymptomatic retinal breaks.
Topics: Cryosurgery; Humans; Laser Coagulation; Retinal Detachment; Retinal Perforations; Slit Lamp; Vitreous Detachment
PubMed: 24853827
DOI: 10.1111/aos.12447 -
Alimentary Pharmacology & Therapeutics Sep 2016With an overall incidence of 3.5%, pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Periprocedural hydration may... (Review)
Review
BACKGROUND
With an overall incidence of 3.5%, pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Periprocedural hydration may prevent post-ERCP pancreatitis by maintaining pancreatic microperfusion, thereby inhibiting the pancreatic inflammatory response. However, the evidence for periprocedural hydration as a preventive measure is unclear.
AIM
To conduct a systematic review to assess the evidence regarding periprocedural hydration as a preventive measure for post-ERCP pancreatitis.
METHODS
We searched PubMed and EMBASE databases and adhered to the PRISMA guidelines. We included studies addressing periprocedural hydration as a preventive measure to reduce frequency and severity of post-ERCP pancreatitis. Study quality was assessed by using the MINORS and Cochrane Collaboration's tool.
RESULTS
Six studies with a total of 1102 patients were included. Two randomised controlled trials reported a decreased incidence of post-ERCP pancreatitis after hydration: 0% vs. 17% (P = 0.016) and 5.3% vs. 22.7% (P = 0.002). A third trial and two case-controls studies did not report significant differences. Two retrospective studies found that patients with mild post-ERCP pancreatitis had received significantly more fluids during (mean 940 mL vs. 810 mL; P = 0.031) or after ERCP (median 2834 mL vs. 2044 mL; P < 0.02) compared to patients with moderate/severe disease. Adverse events of periprocedural hydration were not reported in any of the included studies. The different methodologies of the included studies precluded a formal data synthesis.
CONCLUSIONS
There is some evidence to suggest that hydration affords protection against post-ERCP pancreatitis, but study heterogeneity precludes firm conclusions. Adequately powered randomised trials are needed to evaluate the preventive effect of periprocedural hydration.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Databases, Factual; Female; Humans; Hypodermoclysis; Incidence; Male; Pancreatitis; Perioperative Care; Postoperative Complications; Retrospective Studies
PubMed: 27444408
DOI: 10.1111/apt.13744