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The Cochrane Database of Systematic... Jun 2021There has been extensive debate in the surgical literature regarding the optimum surgical access approach to the infrarenal abdominal aorta during an operation to repair... (Meta-Analysis)
Meta-Analysis
BACKGROUND
There has been extensive debate in the surgical literature regarding the optimum surgical access approach to the infrarenal abdominal aorta during an operation to repair an abdominal aortic aneurysm. The published trials comparing retroperitoneal (RP) and transperitoneal (TP) aortic surgery show conflicting results. This is an update of the review first published in 2016.
OBJECTIVES
To assess the effectiveness and safety of the retroperitoneal versus transperitoneal approach for elective open abdominal aortic aneurysm repair on mortality, complications, hospital stay and blood loss.
SEARCH METHODS
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trials registers to 30 November 2020. The review authors searched the Chinese Biomedical Literature Database and handsearched reference lists of relevant articles to identify additional trials.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) that assessed the RP approach versus the TP approach for elective open abdominal aortic aneurysm (AAA) repair. There were no restrictions on language or publication status.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data from the included trials. We resolved any disagreements through discussion with a third review author. Two review authors independently assessed the risk of bias in included trials with the Cochrane risk of bias tool. For dichotomous outcomes, we calculated the odds ratio (OR) with the corresponding 95% confidence interval (CI). For continuous data, we calculated a pooled estimate of treatment effect by calculating the mean difference (MD) and standard deviation (SD) with corresponding 95% CIs. We pooled data using a fixed-effect model, unless we identified heterogeneity, in which case we used a random-effects model. We used GRADE to assess the overall certainty of the evidence. We evaluated the outcomes of mortality, complications, intensive care unit (ICU) stay, hospital stay, blood loss, aortic cross-clamp time and operating time.
MAIN RESULTS
We identified no new studies from the updated searches. After reassessment, we included one study which had previously been excluded. Five RCTs with a combined total of 152 participants are included. The overall certainty of the evidence ranged from low to very low because of the low methodological quality of the included trials (unclear random sequence generation method and allocation concealment, and no blinding of outcome assessors), small sample sizes, small number of events, high heterogeneity and inconsistency between the included trials, no power calculations and relatively short follow-up. There was no evidence of a difference between the RP approach and the TP approach regarding mortality (odds ratio (OR) 0.32, 95% CI 0.01 to 8.25; 3 studies, 110 participants; very low-certainty evidence). Similarly, there was no evidence of a difference in complications such as hematoma (OR 0.90, 95% CI 0.13 to 6.48; 2 studies, 75 participants; very low-certainty evidence), abdominal wall hernia (OR 10.76, 95% CI 0.55 to 211.78; 1 study, 48 participants; very low-certainty evidence), or chronic wound pain (OR 2.20, 95% CI 0.36 to 13.34; 1 study, 48 participants; very low-certainty evidence) between the RP and TP approaches in participants undergoing elective open AAA repair. The RP approach may reduce ICU stay (mean difference (MD) -19.02 hours, 95% CI -30.83 to -7.21; 3 studies, 106 participants; low-certainty evidence); hospital stay (MD -3.30 days, 95% CI -4.85 to-1.75; 5 studies, 152 participants; low-certainty evidence); and blood loss (MD -504.87 mL, 95% CI -779.19 to -230.56; 4 studies, 129 participants; very low-certainty evidence). There was no evidence of a difference between the RP approach and the TP approach regarding aortic cross-clamp time (MD 0.69 min, 95% CI -7.23 to 8.60; 4 studies, 129 participants; very low-certainty evidence) or operating time (MD -15.94 min, 95% CI -34.76 to 2.88; 4 studies, 129 participants; very low-certainty evidence).
AUTHORS' CONCLUSIONS
Very low-certainty evidence from five small RCTs showed no clear evidence of a difference between the RP approach and the TP approach for elective open AAA repair in terms of mortality, or for rates of complications including hematoma (very low-certainty evidence), abdominal wall hernia (very low-certainty evidence), or chronic wound pain (very low-certainty evidence). However, a shorter intensive care unit (ICU) stay and shorter hospital stay was probably indicated following the RP approach compared to the TP approach (both low-certainty evidence). A possible reduction in blood loss was also shown after the RP approach (very low-certainty evidence). There is no clear difference between the RP approach and TP approach in aortic cross-clamp time or operating time. Further well-designed, large-scale RCTs assessing the RP approach versus TP approach for elective open AAA repair are required.
Topics: Aortic Aneurysm, Abdominal; Bias; Blood Loss, Surgical; Elective Surgical Procedures; Hematoma; Humans; Length of Stay; Operative Time; Pain, Postoperative; Peritoneum; Postoperative Complications; Randomized Controlled Trials as Topic; Retroperitoneal Space
PubMed: 34152003
DOI: 10.1002/14651858.CD010373.pub3 -
World Journal of Surgical Oncology Sep 2020Ganglioneuromas (GNs) are extremely rare, slowly growing, benign tumors that can arise from Schwann cells, ganglion cells, and neuronal or fibrous tissues. Due to their...
BACKGROUND
Ganglioneuromas (GNs) are extremely rare, slowly growing, benign tumors that can arise from Schwann cells, ganglion cells, and neuronal or fibrous tissues. Due to their origin from the sympathetic neural crest, they show neuroendocrine potential; however, most are reported to be hormonally inactive. Nevertheless, complete surgical removal is recommended for symptom control or for the prevention of potential malignant degeneration.
CASE REPORT
A 30-year-old female was referred to our oncologic center due to a giant retroperitoneal and mediastinal mass detected in computed tomography (CT) scans. The initial symptoms were transient nausea, diarrhea, and crampy abdominal pain. There was a positive family history including 5 first- and second-degree relatives. Presurgical biopsy revealed a benign ganglioneuroma. Total resection (TR) of a 35 × 25 × 25 cm, 2550-g tumor was obtained successfully via laparotomy combined with thoracotomy and partial incision of the diaphragm. Histopathological analysis confirmed the diagnosis. Surgically challenging aspects were the bilateral tumor invasion from the retroperitoneum into the mediastinum through the aortic hiatus with the need of a bilateral 2-cavity procedure, as well as the tumor-related displacement of the abdominal aorta, the mesenteric vessels, and the inferior vena cava. Due to their anatomic course through the tumor mass, the lumbar aortic vessels needed to be partially resected. Postoperative functioning was excellent without any sign of neurologic deficit.
CONCLUSION
Here, we present the largest case of a TR of a GN with retroperitoneal and mediastinal expansion. On review of the literature, this is the largest reported GN resected and was performed safely. Additionally, we present the first systematic literature review for large GN (> 10 cm) as well as for resected tumors growing from the abdominal cavity into the thoracic cavity.
Topics: Adult; Female; Ganglioneuroma; Humans; Mediastinal Neoplasms; Prognosis; Retroperitoneal Neoplasms; Retroperitoneal Space; Tomography, X-Ray Computed
PubMed: 32948207
DOI: 10.1186/s12957-020-02016-1 -
Biomolecules & Biomedicine May 2024At present, research on blunt abdominal aortic injury (BAAI) is limited, with the majority being case reports. Consequently, there is a significant knowledge gap...
At present, research on blunt abdominal aortic injury (BAAI) is limited, with the majority being case reports. Consequently, there is a significant knowledge gap concerning this condition. To address this, we conducted a systematic review by extensively searching major databases. We included all literature that provided individual (non-identifiable) data on BAAI patients, irrespective of the study design. Furthermore, we undertook regression analyses to identify predictors of death after BAAI. The search yielded 2,099 results, leading to the inclusion of 102 case reports and one conference abstract. Using the Joanna Briggs Institute (JBI) checklist for assessment, all studies were deemed of medium to high quality. In total, 133 patients were included, with a median age of 34 years, and 73.7% being male. The predominant clinical manifestation was pain, reported in 65.6% of patients. The most frequently observed aortic lesion severity was grade A (intimal tear or intramural hematoma) at 46.9%, and the most common lesion location was zone III (infrarenal aorta) in 88.3% of cases. The overall mortality after BAAI was 15.3%. Multivariate regression analyses revealed the following predictors of death after BAAI: lower limb ischemia (relative risk [RR] = 7.137, 95% confidence interval [CI] 1.154 - 44.161), cardiopulmonary arrest (RR = 10.250, 95% CI 1.452 - 72.344), and injuries to body parts other than the abdomen and lumbar spine (RR = 2.593, 95% CI 1.189 - 5.655). In conclusion, this review provides a detailed quantitative summary of BAAI's clinical manifestations, diagnosis, treatment, and prognosis, emphasizing its high mortality rate and identifying three critical variables as predictors of death.
Topics: Adult; Female; Humans; Male; Abdominal Injuries; Aorta, Abdominal; Prognosis; Wounds, Nonpenetrating
PubMed: 37865918
DOI: 10.17305/bb.2023.9831 -
Journal of Vascular Surgery Sep 2020The efficacy and safety of placement of a proximal covered stent graft combined with a distal bare stent are controversial because of the lack of evidence. This... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The efficacy and safety of placement of a proximal covered stent graft combined with a distal bare stent are controversial because of the lack of evidence. This systematic review and meta-analysis compared the outcomes of combined proximal covered stent grafting with distal bare stenting (BS group) and proximal covered stent grafting without distal bare stenting (non-BS group).
METHODS
The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases and key references were searched up to January 26, 2019. Predefined outcomes of interest were mortality, morbidity, and postoperative assessment of aortic remodeling. We pooled risk ratios (RRs) of the outcomes of interest using fixed effects model or random effects model.
RESULTS
Overall, eight observational studies involving 914 patients were included. There were no significant differences in overall aorta-related mortality (RR, 0.54; confidence interval [CI], 0.24-1.24; P = .15), complete thoracic false lumen (FL) thrombosis rate (RR, 1.23; CI, 0.83-1.81; P = .30), or complete abdominal FL thrombosis rate (RR, 1.96; CI, 0.68-5.69; P = .21) between the BS group and the non-BS group. The BS group had a lower rate of partial thoracic FL thrombosis (RR, 0.40; CI, 0.25-0.65; P = .0002), a lower stent graft-induced new entry rate (RR, 0.08; CI, 0.02-0.41; P = .003), and a lower reintervention rate (RR, 0.42; CI, 0.26-0.69; P = .0005).
CONCLUSIONS
Combined proximal covered stent grafting with distal adjunctive bare stenting had the potential to reduce the partial thoracic FL thrombosis rate and the rates of stent graft-induced new entry and reintervention but was not associated with lower aorta-related mortality or the complete FL thrombosis rate. Further research with a stricter methodology is needed.
Topics: Aortic Dissection; Aortic Aneurysm; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Female; Humans; Male; Middle Aged; Observational Studies as Topic; Risk Assessment; Risk Factors; Stents; Treatment Outcome
PubMed: 32304727
DOI: 10.1016/j.jvs.2020.02.052 -
Asian Journal of Surgery Oct 2019To provide a meta-analysis of studies evaluating long-term all-cause mortality, aneurysm-related mortality and re-intervention after open or endovascular repair for... (Meta-Analysis)
Meta-Analysis
To provide a meta-analysis of studies evaluating long-term all-cause mortality, aneurysm-related mortality and re-intervention after open or endovascular repair for abdominal aortic aneurysm. Electronic bibliographic sources were interrogated using a combination of free text and controlled vocabulary searches to identify studies comparing the long-term outcomes of open and endovascular repair for abdominal aortic aneurysm. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Fixed effect or random effects models were used. We retrieved 4 randomized controlled trials (RCTs; 2,783 patients), 7 nonrandomized trials (86,035 patients). The primary outcome was all-cause mortality. Heterogeneity was high and publication bias could not be excluded. Despite these limitations, the analysis showed that open and endovascular abdominal aortic aneurysm repair had similar all-cause mortality (OR 1.16, 95% CI, 0.89-1.51) over 5 years follow up, which was maintained after at least 10 years of follow-up (OR 0.87, 95% CI, 0.73-1.03). There was no significant difference in aneurysm-related mortality by 5 years or longer follow-up. A significantly lower proportion of patients undergoing open repair required reintervention (OR 0.38, 95% CI 0.24-0.64), which was maintained over 5 years of follow-up. There is no long-term survival difference between the patients who underwent open or endovascular aneurysm repair. There is significantly higher risk of reinterventions after endovascular aneurysm repair.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Databases, Bibliographic; Endovascular Procedures; Follow-Up Studies; Humans; Randomized Controlled Trials as Topic; Reoperation; Risk; Survival Rate; Time Factors; Treatment Outcome; Vascular Surgical Procedures
PubMed: 30914154
DOI: 10.1016/j.asjsur.2019.01.014 -
Arteriosclerosis, Thrombosis, and... Apr 2021[Figure: see text]. (Meta-Analysis)
Meta-Analysis
[Figure: see text].
Topics: Animals; Anti-Inflammatory Agents; Aorta, Abdominal; Aortic Aneurysm, Abdominal; Dilatation, Pathologic; Disease Models, Animal; Disease Progression; Female; Fibrinolytic Agents; Male; Mice; Mice, Inbred C57BL; Mice, Knockout, ApoE; Protease Inhibitors; Receptors, LDL; Renin-Angiotensin System; Time Factors
PubMed: 33567871
DOI: 10.1161/ATVBAHA.121.315942 -
Biomedicines Oct 2021The aim of this systematic review was to pool evidence from studies testing if pentagalloyl glucose (PGG) limited aortic expansion in animal models of abdominal aortic...
BACKGROUND
The aim of this systematic review was to pool evidence from studies testing if pentagalloyl glucose (PGG) limited aortic expansion in animal models of abdominal aortic aneurysm (AAA).
METHODS
The review was conducted according to the PRISMA guidelines and registered with PROSPERO. The primary outcome was aortic expansion assessed by direct measurement. Secondary outcomes included aortic expansion measured by ultrasound and aortic diameter at study completion. Sub analyses examined the effect of PGG delivery in specific forms (nanoparticles, periadventitial or intraluminal), and at different times (from the start of AAA induction or when AAA was established), and tested in different animals (pigs, rats and mice) and AAA models (calcium chloride, periadventitial, intraluminal elastase or angiotensin II). Meta-analyses were performed using Mantel-Haenszel's methods with random effect models and reported as mean difference (MD) and 95% confidence intervals (CIs). Risk of bias was assessed with a customized tool.
RESULTS
Eleven studies reported in eight publications involving 214 animals were included. PGG significantly reduced aortic expansion measured by direct observation (MD: -66.35%; 95% CI: -108.44, -24.27; = 0.002) but not ultrasound (MD: -32.91%; 95% CI: -75.16, 9.33; = 0.127). PGG delivered intravenously within nanoparticles significantly reduced aortic expansion, measured by both direct observation (MD: -116.41%; 95% CI: -132.20, -100.62; < 0.001) and ultrasound (MD: -98.40%; 95% CI: -113.99, -82.81; < 0.001). In studies measuring aortic expansion by direct observation, PGG administered topically to the adventitia of the aorta (MD: -28.41%; 95% CI -46.57, -10.25; = 0.002), studied in rats (MD: -56.61%; 95% CI: -101.76, -11.46; = 0.014), within the calcium chloride model (MD: -56.61%; 95% CI: -101.76, -11.46; = 0.014) and tested in established AAAs (MD: -90.36; 95% CI: -135.82, -44.89; < 0.001), significantly reduced aortic expansion. The findings of other analyses were not significant. The risk of bias of all studies was high.
CONCLUSION
There is inconsistent low-quality evidence that PGG inhibits aortic expansion in animal models.
PubMed: 34680560
DOI: 10.3390/biomedicines9101442 -
Arquivos Brasileiros de Cirurgia... 2020Superior mesenteric artery (SMA) usually arises from the abdominal aorta, just below the celiac trunk and it supplies the midgut-derived embryonic structures. Anatomical...
INTRODUCTION
Superior mesenteric artery (SMA) usually arises from the abdominal aorta, just below the celiac trunk and it supplies the midgut-derived embryonic structures. Anatomical variations in this vessel contribute to problems in the formation and/or absorption of this part of the intestine and its absence has been recognized as the cause of congenital duodenojejunal atresia.
OBJECTIVE
To analyze SMA anatomical variations in humans and the possible associated clinical and surgical implications.
METHODS
This is a systematic review of papers indexed in PubMed, SciELO, Springerlink, Science Direct, Lilacs, and Latindex databases. The search was performed by two independent reviewers between September and December 2018. Original studies involving SMA variations in humans were included. SMA presence/absence, level, place of origin and its terminal branches were considered.
RESULTS
At the end of the search, 18 studies were selected, characterized as for the sample, method to evaluate the anatomical structure and main results. The most common type of variation was when SMA originated from the right hepatic artery (6.13%). Two studies (11.11%) evidenced the inferior mesenteric artery originating from the SMA, whereas other two (11.11%) found the SMA sharing the same origin of the celiac trunk.
CONCLUSION
SMA variations are not uncommon findings and their reports evidenced through the scientific literature demonstrate a great role for the development of important clinical conditions, making knowledge about this subject relevant to surgeons and professionals working in this area.
Topics: Celiac Artery; Hepatic Artery; Humans; Mesenteric Artery, Superior; Surgeons
PubMed: 32844880
DOI: 10.1590/0102-672020190001e1508 -
The Cochrane Database of Systematic... Oct 2019Aortic dissection is a separation of the aortic wall, caused by blood flowing through a tear in the inner layer of the aorta. Aortic dissection is an infrequent but... (Meta-Analysis)
Meta-Analysis
Combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending aortic stent graft repair for complicated type B aortic dissections.
BACKGROUND
Aortic dissection is a separation of the aortic wall, caused by blood flowing through a tear in the inner layer of the aorta. Aortic dissection is an infrequent but life-threatening condition. The incidence of aortic dissection is 3 to 6 per 10,000 per year in the Western population, and can be up to 43 per 10,000 per year in the Eastern population. Over 20% of people with an aortic dissection do not reach a hospital alive. After admission, the mortality rates for people with an aortic dissection are between 10% and 20% for those who received endovascular treatment, and between 20% and 30% for those who had open surgery. Thoracic endovascular aortic repair (TEVAR) is the standard endovascular method to treat complicated type B aortic dissection (aortic dissections without involvement of the ascending aorta). Although TEVAR is less invasive than open surgery and has a better long-term aortic remodeling effect than conservative medical treatment, favourable aortic remodelling is usually limited to the thoracic aortic segment. TEVAR cannot be extended into the abdominal aorta because it could cover the ostia of the reno-visceral arteries. Thus, the abdominal aorta is still at risk of progressive aneurysmal degeneration. The PETTICOAT (provisional extension to induce complete attachment) technique, with proximal endograft and distal bare metal stent, was proposed in 2006 to address this issue. The concept of this technique was to implant a distal bare metal stent into the aortic true lumen, distal to the proximal endograft, to stabilize the distal collapsed intimal flap, while allowing blood flow to reno-visceral arteries. Therefore, the PETTICOAT technique was considered to be related to a more extensive aortic remodelling for people with type B aortic dissection, especially in the area of the abdominal aorta. However, it is still unclear whether the PETTICOAT technique is superior to standard TEVAR.
OBJECTIVES
To assess the effects of combined proximal descending aortic endografting plus distal bare metal stenting versus conventional proximal descending aortic stent graft repair for treating complicated type B aortic dissections.
SEARCH METHODS
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 November 2018. We also undertook reference checking and citation searching to identify additional studies.
SELECTION CRITERIA
We considered all randomised controlled trials which compared the outcome of complicated type B aortic dissection, when treated by combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending aortic stent graft repair.
DATA COLLECTION AND ANALYSIS
Two independent review authors assessed all references identified by the Cochrane Vascular Information Specialist. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions.
MAIN RESULTS
We found no trials that met the inclusion criteria for this review.
AUTHORS' CONCLUSIONS
We identified no randomised controlled trials and therefore cannot draw any definite conclusion on this topic. Evidence from non-randomised studies appears to be favourable in the short-term, for combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) to solve the problem of unfavourable distal aortic remodeling. Randomised controlled trials are warranted to provide solid evidence on this topic. Evidence from cohort studies with large sample sizes would also be helpful in guiding clinical practice.
Topics: Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Randomized Controlled Trials as Topic; Stents
PubMed: 31684692
DOI: 10.1002/14651858.CD013149.pub2 -
European Journal of Vascular and... Sep 2021To investigate whether patients with severe infrarenal aortic neck angulation have worse outcomes than those without severe angulation after endovascular aneurysm repair... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To investigate whether patients with severe infrarenal aortic neck angulation have worse outcomes than those without severe angulation after endovascular aneurysm repair (EVAR).
DATA SOURCES
The HDAS (Healthcare Database Advanced Search) interface developed by NICE (National Institute for Health and Care Excellence) was used to search electronic bibliographic databases.
REVIEW METHODS
Studies comparing outcomes of standard EVAR in patients with and without severe neck angulation were considered. Pooled outcome estimates were calculated using the odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI), using the Mantel-Haenszel or inverse variance method, as appropriate. Random effects models of meta-analysis were applied. The GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) methodology was used to assess the certainty of evidence.
RESULTS
Ten studies reporting a total of 7 371 patients (1 576 with severe neck angulation and 5 795 without) were included. The studies reported medium term follow up. No statistically significant difference was found for the primary outcomes (overall mortality: HR 1.27, 95% CI 0.88 - 1.85, low certainty; aneurysm related mortality: HR 1.07, 95% CI 0.80 - 1.44, moderate certainty; aneurysm rupture: HR 1.41, 95% CI 0.66 - 2.99, low certainty). The hazard of type Ia endoleak (HR 1.86, 95% CI 1.32 - 2.61) and re-intervention was higher in patient with severe angulation (HR 1.24, 95% CI 1.01 - 1.54), but there was no significant difference in the odds of adjunctive procedures (OR 1.23, 95% CI 0.48 - 3.11), or the hazard of sac expansion (HR 0.83, 95% CI 0.44 - 1.55) or stent migration (HR 1.22, 95% CI 0.78 - 1.92). Meta-analysis of studies that conducted multiple Cox regression analysis showed no significant difference for any of the primary outcomes.
CONCLUSION
Severe neck angulation may not be a poor prognostic indicator for overall/aneurysm related mortality and rupture in the medium term after EVAR but may increase the risk of late type 1 endoleaks and re-intervention; therefore, patients require close surveillance.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Humans; Models, Statistical; Odds Ratio; Postoperative Complications; Prognosis; Reoperation; Risk Factors; Treatment Outcome
PubMed: 34301460
DOI: 10.1016/j.ejvs.2021.05.014