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The Journal of Trauma and Acute Care... Nov 2022Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute care setting. Consequently, this systematic review and network meta-analysis, comparing one-stage (CBD exploration or intraoperative endoscopic retrograde cholangiopancreatography [ERCP] with simultaneous cholecystectomy) and two-stage (precholecystectomy or postcholecystectomy ERCP) procedures, was undertaken with the main outcomes of interest being postprocedural complications and hospital length of stay (LOS).
METHODS
PubMed, SCOPUS, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were methodically queried for articles from 2010 to 2021. The search terms were a combination of medical subject headings terms and the subsequent terms: gallstone; common bile duct (stone); choledocholithiasis; cholecystitis; endoscopic retrograde cholangiography/ERCP; common bile duct exploration; intraoperative, preoperative, perioperative, and postoperative endoscopic retrograde cholangiography; stone extraction; and one-stage and two-stage procedure. Studies that compared two procedures or more were included, whereas studies not recording complications (bile leak, hemorrhage, pancreatitis, perforation, intra-abdominal infections, and other infections) or LOS were excluded. A network meta-analysis was conducted to compare the four different approaches for managing CBD stones.
RESULTS
A total of 16 studies (8,644 participants) addressing the LOS and 41 studies (19,756 participants) addressing postprocedural complications were included in the analysis. The one-stage approaches were associated with a decrease in LOS compared with the two-stage approaches. Common bile duct exploration demonstrated a lower overall risk of complications compared with preoperative ERCP, but there were no differences in the overall risk of complications in the remaining comparisons. However, differences in specific postprocedural complications were detected between the four different approaches managing CBD stones.
CONCLUSION
This network meta-analysis suggests that both laparoscopic CBD exploration and intraoperative ERCP have equally good outcomes and provide a preferable single-anesthesia patient pathway with a shorter overall length of hospital stay compared with the two-stage approaches.
LEVEL OF EVIDENCE
Systematic Review/Meta Analysis; Level III.
Topics: Humans; Gallstones; Sphincterotomy, Endoscopic; Cholecystectomy, Laparoscopic; Network Meta-Analysis; Choledocholithiasis; Cholangiopancreatography, Endoscopic Retrograde; Common Bile Duct
PubMed: 35939370
DOI: 10.1097/TA.0000000000003755 -
BMJ (Clinical Research Ed.) Mar 2022To systematically compare the effect of direct oral anticoagulants and low molecular weight heparin for thromboprophylaxis on the benefits and harms to patients... (Meta-Analysis)
Meta-Analysis
Benefits and harms of direct oral anticoagulation and low molecular weight heparin for thromboprophylaxis in patients undergoing non-cardiac surgery: systematic review and network meta-analysis of randomised trials.
OBJECTIVE
To systematically compare the effect of direct oral anticoagulants and low molecular weight heparin for thromboprophylaxis on the benefits and harms to patients undergoing non-cardiac surgery.
DESIGN
Systematic review and network meta-analysis of randomised controlled trials.
DATA SOURCES
Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL), up to August 2021.
REVIEW METHODS
Randomised controlled trials in adults undergoing non-cardiac surgery were selected, comparing low molecular weight heparin (prophylactic (low) or higher dose) with direct oral anticoagulants or with no active treatment. Main outcomes were symptomatic venous thromboembolism, symptomatic pulmonary embolism, and major bleeding. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for network meta-analyses. Abstracts and full texts were screened independently in duplicate. Data were abstracted on study participants, interventions, and outcomes, and risk of bias was assessed independently in duplicate. Frequentist network meta-analysis with multivariate random effects models provided odds ratios with 95% confidence intervals, and GRADE (grading of recommendations, assessment, development, and evaluation) assessments indicated the certainty of the evidence.
RESULTS
68 randomised controlled trials were included (51 orthopaedic, 10 general, four gynaecological, two thoracic, and one urological surgery), involving 45 445 patients. Low dose (odds ratio 0.33, 95% confidence interval 0.16 to 0.67) and high dose (0.19, 0.07 to 0.54) low molecular weight heparin, and direct oral anticoagulants (0.17, 0.07 to 0.41) reduced symptomatic venous thromboembolism compared with no active treatment, with absolute risk differences of 1-100 per 1000 patients, depending on baseline risks (certainty of evidence, moderate to high). None of the active agents reduced symptomatic pulmonary embolism (certainty of evidence, low to moderate). Direct oral anticoagulants and low molecular weight heparin were associated with a 2-3-fold increase in the odds of major bleeding compared with no active treatment (certainty of evidence, moderate to high), with absolute risk differences as high as 50 per 1000 in patients at high risk. Compared with low dose low molecular weight heparin, high dose low molecular weight heparin did not reduce symptomatic venous thromboembolism (0.57, 0.26 to 1.27) but increased major bleeding (1.87, 1.06 to 3.31); direct oral anticoagulants reduced symptomatic venous thromboembolism (0.53, 0.32 to 0.89) and did not increase major bleeding (1.23, 0.89 to 1.69).
CONCLUSIONS
Direct oral anticoagulants and low molecular weight heparin reduced venous thromboembolism compared with no active treatment but probably increased major bleeding to a similar extent. Direct oral anticoagulants probably prevent symptomatic venous thromboembolism to a greater extent than prophylactic low molecular weight heparin.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42018106181.
Topics: Anticoagulants; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Network Meta-Analysis; Postoperative Complications; Pulmonary Embolism; Randomized Controlled Trials as Topic; Surgical Procedures, Operative; Treatment Outcome; Venous Thromboembolism
PubMed: 35264372
DOI: 10.1136/bmj-2021-066785 -
Journal of the American College of... May 2021It is increasingly recognized that non-opioid analgesia is an important analgesia in the perioperative period. Specifically, NSAIDs (nonsteroidal anti-inflammatory... (Meta-Analysis)
Meta-Analysis
BACKGROUND
It is increasingly recognized that non-opioid analgesia is an important analgesia in the perioperative period. Specifically, NSAIDs (nonsteroidal anti-inflammatory drugs) have been touted as an adjunct, or even replacement, for opioids. However, uptake of NSAIDs has been slow due to concern for side effects, including bleeding. We sought to understand the risk of bleeding caused by NSAIDs in the perioperative period.
STUDY DESIGN
A physician-librarian team performed a search of electronic databases (MEDLINE, EMBASE), using search terms covering the targeted intervention (use of NSAIDs) and outcomes of interest (surgical complications, bleeding), limited to English language articles of any date. We performed a systematic review and meta-analysis of the data.
RESULTS
A total of 2,521 articles were screened, and 229 were selected on the basis of title and abstract for detailed assessment. Including reference searching, 74 manuscripts met inclusion criteria spanning years 1987-2019. These studies included 151,031 patients. Studies included 12 types of NSAIDs, the most common being ketorolac, diclofenac, and ibuprofen, over a wide-range of procedures, from otorhinolaryngology (ENT), breast, abdomen, plastics, and more. More than half were randomized control trials. The meta-analyses for hematoma, return to the operating room for bleeding, and blood transfusions showed no difference in risk in any of 3 categories studied between the NSAID vs non-NSAID groups (p = 0.49, p = 0.79, and p = 0.49, respectively). Quality scoring found a wide range of quality, with scores ranging from lowest quality of 12 to highest quality of 25, out of a total of 27 (average = 16).
CONCLUSIONS
NSAIDs are unlikely to be the cause of postoperative bleeding complications. This literature covers a large number of patients and remains consistent across types of NSAIDs and operations.
Topics: Analgesia; Anti-Inflammatory Agents, Non-Steroidal; Blood Loss, Surgical; Blood Transfusion; Diclofenac; Humans; Ibuprofen; Ketorolac; Pain, Postoperative; Pain, Procedural; Perioperative Period; Postoperative Hemorrhage; Surgical Procedures, Operative; Treatment Outcome
PubMed: 33515678
DOI: 10.1016/j.jamcollsurg.2021.01.005 -
Surgery May 2023The aim of this meta-analysis and systematic review was to evaluate the association between intraoperative bile cultures and postoperative complications of patients... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The aim of this meta-analysis and systematic review was to evaluate the association between intraoperative bile cultures and postoperative complications of patients undergoing pancreaticoduodenectomy.
METHODS
A detailed literature search was performed from January 2015 to July 2022 in PubMed, Web of Science, Google Scholar, and EMBASE for related research publications. The data were extracted, screened, and graded independently. An analysis of pooled data was performed, and a risk ratio with corresponding confidence intervals was calculated and summarized.
RESULTS
A total of 8 articles were included with 1,778 pancreaticoduodenectomy patients who had an intraoperative bile culture performed. A systematic review demonstrated that some of the most common organisms isolated in a positive intraoperative bile culture were Enterococcus species, Klebsiella species, and E. coli. Four studies also showed that specific microorganisms were associated with specific postoperative complications (surgical site infection and intra-abdominal abscess). The postoperative complications that were evaluated for an association with a positive intraoperative bile culture were surgical site infections (risk ratio = 2.33, 95% confidence interval [1.47-3.69], P < .01), delayed gastric emptying (risk ratio = 1.23, 95% confidence interval [0.63-2.38], P = n.s.), 90-day mortality (risk ratio = 0.68, 95% confidence interval [0.01-52.76], P = n.s.), postoperative pancreatic hemorrhage (risk ratio = 1.70, 95% confidence interval [0.33-8.74], P = n.s.), intra-abdominal abscess (risk ratio = 1.70, 95% confidence interval [0.38-7.56], P = n.s.), and postoperative pancreatic fistula (risk ratio = 0.97, 95% confidence interval [0.72-1.32], P = n.s.).
CONCLUSION
The cumulative data suggest that a positive intraoperative bile culture has no association with predicting the postoperative complications of delayed gastric emptying, 90-day mortality, postoperative pancreatic hemorrhage, intra-abdominal abscess, or postoperative pancreatic fistula. However, the data also suggest that a positive intraoperative bile culture was associated with a patient developing a surgical site infection.
Topics: Humans; Pancreaticoduodenectomy; Surgical Wound Infection; Pancreatic Fistula; Bile; Gastroparesis; Escherichia coli; Pancreatic Diseases; Postoperative Hemorrhage; Abdominal Abscess; Postoperative Complications
PubMed: 36707272
DOI: 10.1016/j.surg.2022.12.012 -
Ear, Nose, & Throat Journal Feb 2021In 2005, the National Prospective Tonsillectomy Audit was conducted by the Royal College of Surgeons England, reporting hot tonsillectomy techniques being associated...
INTRODUCTION
In 2005, the National Prospective Tonsillectomy Audit was conducted by the Royal College of Surgeons England, reporting hot tonsillectomy techniques being associated with more postoperative pain and hemorrhage when compared with dissection. In 2006, the National Institute of Clinical Excellence declared its position on laser tonsillectomy reporting that bleeding may be less intraoperatively but is more postoperatively, that initial pain may be less but medium term is more and that healing is delayed.
AIM
To revisit the literature surrounding laser tonsil surgery and assess the aforementioned factors for any trend changes.
METHODOLOGY
A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-style systematic review conducted in July 2019 searched Embase, Medline, and Cochrane databases for randomized controlled trials comparing laser tonsil surgery with other techniques with the terms laser, tonsillectomy, and tonsillotomy for nonmalignant indications. A total of 14 articles were evaluated.
RESULTS
A total of 1133 patients received surgery accounting for a total of 2266 tonsil removals. A variety of laser techniques were used including CO2 (66%) potassium-titanyl-phosphate (19%) and contact diode (15%). Nonlaser techniques included dissection (62%), diathermy (20%), and coblation (18%). The summated conclusions suggest that laser techniques are superior regarding intraoperative bleeding and procedure duration. Laser techniques also provide equivocal or superior outcomes regarding postoperative hemorrhage, pain, and total healing time.
CONCLUSION
Outcomes following laser surgery in recent years suggest an overall improvement. This could be due to enhanced familiarity with techniques and established centers performing laser procedures more routinely.
Topics: Blood Loss, Surgical; Humans; Laser Therapy; Operative Time; Pain, Postoperative; Postoperative Hemorrhage; Randomized Controlled Trials as Topic; Tonsillectomy; Treatment Outcome; Wound Healing
PubMed: 33048574
DOI: 10.1177/0145561320961747 -
The Cochrane Database of Systematic... Apr 2023Postoperative pain clinical management in neonates has always been a challenging medical issue. Worldwide, several systemic opioid regimens are available for... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Postoperative pain clinical management in neonates has always been a challenging medical issue. Worldwide, several systemic opioid regimens are available for pediatricians, neonatologists, and general practitioners to control pain in neonates undergoing surgical procedures. However, the most effective and safe regimen is still unknown in the current body of literature.
OBJECTIVES
To determine the effects of different regimens of systemic opioid analgesics in neonates submitted to surgery on all-cause mortality, pain, and significant neurodevelopmental disability. Potentially assessed regimens might include: different doses of the same opioid, different routes of administration of the same opioid, continuous infusion versus bolus administration, or 'as needed' administration versus 'as scheduled' administration.
SEARCH METHODS
Searches were conducted in June 2022 using the following databases: Cochrane Central Register of Controlled Trials [CENTRAL], PubMed, and CINAHL. Trial registration records were identified via CENTRAL and an independent search of the ISRCTN registry.
SELECTION CRITERIA
We included randomized controlled trials (RCTs), quasi-randomized, cluster-randomized, and cross-over controlled trials evaluating systemic opioid regimens' effects on postoperative pain in neonates (pre-term or full-term). We considered suitable for inclusion: I) studies evaluating different doses of the same opioid; 2) studies evaluating different routes of administration of the same opioid; 3) studies evaluating the effectiveness of continuous infusion versus bolus infusion; and 4) studies establishing an assessment of an 'as needed' administration versus 'as scheduled' administration.
DATA COLLECTION AND ANALYSIS
According to Cochrane methods, two investigators independently screened retrieved records, extracted data, and appraised the risk of bias. We stratified meta-analysis by the type of intervention: studies evaluating the use of opioids for postoperative pain in neonates through continuous infusion versus bolus infusion and studies assessing the 'as needed' administration versus 'as scheduled' administration. We used the fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD), standardized mean difference (SMD), median, and interquartile range (IQR) for continuous data. Finally, we used the GRADEpro approach for primary outcomes to evaluate the quality of the evidence across included studies.
MAIN RESULTS
In this review, we included seven randomized controlled clinical trials (504 infants) from 1996 to 2020. We identified no studies comparing different doses of the same opioid, or different routes. The administration of continuous opioid infusion versus bolus administration of opioids was evaluated in six studies, while one study compared 'as needed' versus 'as scheduled' administration of morphine given by parents or nurses. Overall, the effectiveness of continuous infusion of opioids over bolus infusion as measured by the visual analog scale (MD 0.00, 95% confidence interval (CI) -0.23 to 0.23; 133 participants, 2 studies; I² = 0); or using the COMFORT scale (MD -0.07, 95% CI -0.89 to 0.75; 133 participants, 2 studies; I² = 0), remains unclear due to study designs' limitations, such as the unclear risk of attrition, reporting bias, and imprecision among reported results (very low certainty of the evidence). None of the included studies reported data on other clinically important outcomes such as all-cause mortality rate during hospitalization, major neurodevelopmental disability, the incidence of severe retinopathy of prematurity or intraventricular hemorrhage, and cognitive- and educational-related outcomes. AUTHORS' CONCLUSIONS: Limited evidence is available on continuous infusion compared to intermittent boluses of systemic opioids. We are uncertain whether continuous opioid infusion reduces pain compared with intermittent opioid boluses; none of the studies reported the other primary outcomes of this review, i.e. all-cause mortality during initial hospitalization, significant neurodevelopmental disability, or cognitive and educational outcomes among children older than five years old. Only one small study reported on morphine infusion with parent- or nurse-controlled analgesia.
Topics: Child; Child, Preschool; Humans; Infant; Infant, Newborn; Analgesia; Analgesics, Opioid; Clinical Protocols; Morphine; Pain, Postoperative
PubMed: 37018131
DOI: 10.1002/14651858.CD015016.pub3 -
European Journal of Vascular and... Nov 2022The role of antithrombotic therapy in the management of aortic and peripheral aneurysms is unclear. This systematic review and meta-analysis aimed to assess the impact... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
The role of antithrombotic therapy in the management of aortic and peripheral aneurysms is unclear. This systematic review and meta-analysis aimed to assess the impact of antithrombotics on clinical outcomes for aortic and peripheral aneurysms.
METHODS
Medline, Embase, and CENTRAL databases were searched. Randomised controlled trials and observational studies investigating the effect of antithrombotic therapy on clinical outcomes for patients with any aortic or peripheral artery aneurysm were included.
RESULTS
Fifty-nine studies (28 with antiplatelet agents, 12 anticoagulants, two intra-operative heparin, and 16 any antithrombotic agent) involving 122 102 patients were included. Abdominal aortic aneurysm (AAA) growth rate was not significantly associated with the use of antiplatelet therapy (SMD -0.36 mm/year; 95% CI -0.75 - 0.02; p = .060; GRADE certainty: very low). Antithrombotics were associated with increased 30 day mortality for patients with AAAs undergoing intervention (OR 2.30; 95% CI 1.51 - 3.51; p < .001; GRADE certainty: low). Following intervention, antiplatelet therapy was associated with reduced long term all cause mortality (HR 0.84; 95% CI 0.76 - 0.92; p < .001; GRADE certainty: moderate), whilst anticoagulants were associated with increased all cause mortality (HR 1.64; 95% CI 1.14 - 2.37; p = .008; GRADE certainty: very low), endoleak within three years (OR 1.99; 95% CI 1.10 - 3.60; p = .020; I = 60%; GRADE certainty: very low), and an increased re-intervention rate at one year (OR 3.25; 95% CI 1.82 - 5.82; p < .001; I = 35%; GRADE certainty: moderate). Five studies examined antithrombotic therapy for popliteal aneurysms. Meta-analysis was not possible due to heterogeneity.
CONCLUSIONS
There was a lack of high quality data examining antithrombotic therapy for patients with aneurysms. Antiplatelet therapy was associated with a reduction in post-intervention all cause mortality for AAA, whilst anticoagulants were associated with an increased risk of all cause mortality, endoleak, and re-intervention. Large, well designed trials are still required to determine the therapeutic benefits of antithrombotic agents in this setting.
Topics: Humans; Fibrinolytic Agents; Platelet Aggregation Inhibitors; Endoleak; Aortic Aneurysm, Abdominal; Anticoagulants
PubMed: 35853579
DOI: 10.1016/j.ejvs.2022.07.008 -
HPB : the Official Journal of the... Aug 2019Postpancreatectomy hemorrhage is a potentially lethal complication after pancreatic resection. The objective of this systematic review is to provide insight in the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Postpancreatectomy hemorrhage is a potentially lethal complication after pancreatic resection. The objective of this systematic review is to provide insight in the current status of incidence, detection, management and clinical outcomes of late postpancreatectomy hemorrhage.
METHODS
A systematic search was conducted on the literature from February 2007 to July 2018 in PubMed, Embase and the Cochrane library. Included were clinical studies with clinical outcomes on late postpancreatectomy hemorrhage defined according to the International Study Group of Pancreatic Surgery definition (i.e. occurring >24 h after pancreatic resection).
RESULTS
A total of 14 studies on 467 patients with late postpancreatectomy hemorrhage were included. The incidence of late postpancreatectomy hemorrhage ranged from 3% to 16% (weighted mean: 5%). Seventy-four patients received conservative treatment; 252 patients underwent primary endovascular intervention; 82 patients underwent primary relaparotomy; 56 patients underwent primary endoscopic intervention; and three patients died before any intervention could be performed. CT-scan and diagnostic angiography were able to identify the source of hemorrhage in 67% (66/98) and 69% (114/166) of patients, respectively. The most frequent origin of the hemorrhage was the gastroduodenal artery stump (79/275; 29%), followed by the common hepatic artery (51/275; 19%) and splenic artery (32/275; 12%). Overall mortality was 21% (98/464 patients; range 0%-38%). Mortality was lower after primary interventional angiography as compared to primary relaparotomy (16% vs 37% respectively).
CONCLUSIONS
This systematic review provides a comprehensive overview of the current literature for severe late postpancreatectomy hemorrhages. CT-scan and diagnostic angiography are equally sensitive in detecting the bleeding source. Interventional angiography appears to be associated to lower mortality as compared to relaparotomy and endoscopy as first intervention for postpancreatectomy hemorrhage.
Topics: Aged; Conservative Treatment; Female; Hemostasis, Endoscopic; Hemostatic Techniques; Hospital Mortality; Humans; Male; Middle Aged; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Hemorrhage; Prognosis; Reoperation; Risk Assessment; Survival Analysis
PubMed: 30962134
DOI: 10.1016/j.hpb.2019.02.011 -
BMC Medicine Dec 2023Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically review evidence on the safety of short-stay programmes versus usual care for total hip (THR) and knee replacement (KR), and optimal patient selection.
METHODS
A systematic review and meta-analysis. Randomised controlled trials (RCTs) and quasi-experimental studies including a comparator group reporting on 14 safety outcomes (hospital readmissions, reoperations, blood loss, emergency department visits, infection, mortality, neurovascular injury, other complications, periprosthetic fractures, postoperative falls, venous thromboembolism, wound complications, dislocation, stiffness) within 90 days postoperatively in adults ≥ 18 years undergoing primary THR or KR were included. Secondary outcomes were associations between patient demographics or clinical characteristics and patient outcomes. Four databases were searched between January 2000 and May 2023. Risk of bias and certainty of the evidence were assessed.
RESULTS
Forty-nine studies were included. Based upon low certainty RCT evidence, short-stay programmes may not reduce readmission (OR 0.95, 95% CI 0.12-7.43); blood transfusion requirements (OR 1.75, 95% CI 0.27-11.36); neurovascular injury (OR 0.31, 95% CI 0.01-7.92); other complications (OR 0.63, 95% CI 0.26-1.53); or stiffness (OR 1.04, 95% CI 0.53-2.05). For registry studies, there was no difference in readmission, infection, neurovascular injury, other complications, venous thromboembolism, or wound complications but there were reductions in mortality and dislocations. For interrupted time series studies, there was no difference in readmissions, reoperations, blood loss volume, emergency department visits, infection, mortality, or neurovascular injury; reduced odds of blood transfusion and other complications, but increased odds of periprosthetic fracture. For other observational studies, there was an increased risk of readmission, no difference in blood loss volume, infection, other complications, or wound complications, reduced odds of requiring blood transfusion, reduced mortality, and reduced venous thromboembolism. One study examined an outcome relevant to optimal patient selection; it reported comparable blood loss for short-stay male and female participants (p = 0.814).
CONCLUSIONS
There is low certainty evidence that short-stay programmes for THR and KR may have non-inferior 90-day safety outcomes. There is little evidence on factors informing optimal patient selection; this remains an important knowledge gap.
Topics: Male; Adult; Female; Humans; Venous Thromboembolism; Patient Selection; Hemorrhage; Interrupted Time Series Analysis
PubMed: 38129857
DOI: 10.1186/s12916-023-03219-5 -
Journal of Vascular Surgery. Venous and... Sep 2022To assess through literature case analysis how advances in lymphatic imaging, interventional radiology, and lymphatic vascular microsurgery illuminate and improve the... (Review)
Review
OBJECTIVES
To assess through literature case analysis how advances in lymphatic imaging, interventional radiology, and lymphatic vascular microsurgery illuminate and improve the lymphatic-flow status in select patients with Noonan syndrome (NS) who have undergone surgical intervention as a part of their comprehensive and individualized treatment plan. Also, we sought to illustrate the spectrum of lymphatic complications that can occur in this patient population when lymphatic flow through abnormal vasculature is surgically disrupted.
METHODS
A literature review was performed by searching "Noonan AND Lymphatic AND Imaging" in the PubMed database. Inclusion criteria for this study were (1) diagnosis and clinical description of at least one original patient with NS, (2) imaging figures depicting lymphatic structure and function or a description of lymphatic imaging findings when a figure is not present, and (3) documentation of either lymphatic surgical intervention or lymphatic complications resulting from other procedures. Patient cases were first grouped by documented surgical intervention type, then clinical outcomes and lymphatic imaging results were compared.
RESULTS
A total of 18 patient cases from 10 eligible publications were included in our review. Lymphatic imaging findings across all patients included lymphatic vessel dysplasia along with flow disruption (n = 16), thoracic duct malformations (n = 12), dermal lymphatic reflux (n = 7), and dilated lymphatic vessels (n = 4). Lymphovenous anastomosis (n = 4) resulted in rapid improvement of patient symptoms and signs. New-onset lymphatic manifestations noted over 10 to 20 years for two of these patients were chylothorax (n = 1), erysipelas (n = 1), and gradual-onset nonchylous scrotal lymphorrhea (n = 1). Targeted endovascular lymphatic disruption via sclerosis, embolization, or ablation (n = 8) results were mixed depending on the degree of central lymphatic involvement and included resolution of symptoms (n = 1), postoperative abdominal hemorrhage (n = 1), stable condition or minor improvement (n = 5), and death (n = 2). Large lymphatic vessel ligation or accidental incision (n = 6) occurred during thoracotomy (n = 4), scrotoplasty (n = 1), or inguinal lymph node biopsy (n = 1). These resulted in postoperative onset of new-onset regional lymphatic reflux (n = 5), chylothorax (n = 4), death (n = 3), or persistent or unchanged symptoms (n = 1).
CONCLUSIONS
Imaging of the central lymphatics enabled characterization of lymphatic developmental features and guided operative management of lymphatic vascular defects in patients with NS. This review of the literature suggests that the surgical preservation or enhancement of central lymphatic return in patients with NS may improve interventional outcomes, whereas the disruption of central lymph flow has significant potential to cause severe postoperative complications and worsening of the patient's clinical condition.
Topics: Humans; Lymphatic Vessels; Noonan Syndrome; Surgery, Computer-Assisted
PubMed: 35561969
DOI: 10.1016/j.jvsv.2022.03.017