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The Spine Journal : Official Journal of... Dec 2017Aspirin is typically discontinued in spinal surgery because of increased risk of hemorrhagic complications. The risk of perioperative continuation of aspirin in... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND CONTEXT
Aspirin is typically discontinued in spinal surgery because of increased risk of hemorrhagic complications. The risk of perioperative continuation of aspirin in neurosurgery needed to be evaluated.
PURPOSE
This study aimed to evaluate all available evidence about continuation of aspirin and to compare peri- and postoperative blood loss and complication rates between patients that continued aspirin and those who discontinued aspirin perioperatively in spinal surgery.
STUDY SETTING
Systematic review and meta-analysis were carried out.
METHOD
A meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing aspirin continuation with discontinuation were included. Studies using a combination of anticlotting agents or non-spinal procedures were excluded. Operative outcomes (blood loss and operative length) and different complications (surgical site infection [SSI]), stroke, myocardial infarction within 30 days postoperatively) were extracted. Overall prevalence and means were calculated for the reported outcomes in fixed-effects models with heterogeneity (I-squared [I]) and effect modification (P-interaction) assessment.
RESULTS
Out of 1,339 studies, three case series were included in the meta-analysis. No significant differences in mean operating time were seen between the aspirin-continuing group (mean=201.8 minutes, 95% confidence interval [CI]=193.3; 210.3; I=95.4%; 170 patients) and the aspirin-discontinuing group (mean=178.4 minutes, 95% CI=119.1; 237.6; I=93.5%; 200 patients); (P-interaction=0.78). No significant differences in mean perioperative blood loss were seen between the aspirin-continuing group (mean=553.9 milliliters, 95% CI=468.0; 639.9; I=83.4%; 170 patients) and the aspirin-discontinuing group (mean=538.7 milliliters, 95% CI=427.6; 649.8; I=985.5%; 200 patients); (P-interaction=0.96). Similar non-significant differences between the two groups were found for cardiac events, stroke, and surgical site infections.
CONCLUSIONS
This meta-analysis showed an absence of significant differences in perioperative complications between aspirin continuation and discontinuation. Because of the paucity of included studies, further well-designed prospective trials are imperative to demonstrate potential benefit and safety.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Humans; Neurosurgical Procedures; Postoperative Hemorrhage; Risk; Spinal Diseases
PubMed: 28823937
DOI: 10.1016/j.spinee.2017.08.238 -
Neurosurgery Oct 1999Few recommendations have been outlined in the neurosurgical literature regarding when it is safe to initiate postoperative or posthemorrhage anticoagulation (AC), or for... (Review)
Review
OBJECTIVE
Few recommendations have been outlined in the neurosurgical literature regarding when it is safe to initiate postoperative or posthemorrhage anticoagulation (AC), or for what duration it is safe to discontinue AC therapy in patients with clear indications for AC therapy. Our objective was to formulate guidelines for managing AC in neurosurgical patients, based on patients' needs for AC and the risk of complications.
METHODS
We conducted a systematic review of the neurosurgical and general surgical literature pertaining directly to postoperative or posthemorrhage management of AC. In addition, we surveyed the general medical, cardiology, cardiothoracic surgery, general surgery, vascular surgery, and neurology literature to determine the risk of thromboembolic complications when AC is stopped in specific patient groups.
RESULTS
Postoperative bleeding complications occurred more frequently when correction of coagulation abnormalities was inadequate in the preoperative period, when AC was reinstituted in the early (24-48 h) postoperative period, and when AC was supratherapeutic in the postoperative period. Risk of significant thromboembolic complications while off AC varied significantly depending on the primary disease process necessitating AC.
CONCLUSION
Adequate preoperative correction of coagulation abnormalities and strict regulation of coagulation to avoid supratherapeutic AC is essential. Reintroduction of AC after an intracranial hemorrhage treated without surgery, or after a neurosurgical procedure, particularly an intracranial procedure, can be guided by determining whether the patient is at high, moderate, or low risk for thromboembolic complications. On the basis of experimental studies, the patient's thromboembolic risk, and the experience of other surgeons, we propose therapeutic options for use of AC in neurosurgical patients undergoing intracranial procedures.
Topics: Anticoagulants; Clinical Trials as Topic; Humans; Intracranial Hemorrhages; Postoperative Complications; Postoperative Hemorrhage; Risk Factors; Thromboembolism
PubMed: 10515479
DOI: 10.1097/00006123-199910000-00022 -
Annals of Intensive Care Nov 2019The effect of nitric oxide (NO) on renal function is controversial in critical illness. We performed a systematic meta-analysis and trial sequential analysis to...
Effect of nitric oxide on postoperative acute kidney injury in patients who underwent cardiopulmonary bypass: a systematic review and meta-analysis with trial sequential analysis.
BACKGROUND
The effect of nitric oxide (NO) on renal function is controversial in critical illness. We performed a systematic meta-analysis and trial sequential analysis to determine the effect of NO gas on renal function and other clinical outcomes in patients requiring cardiopulmonary bypass (CPB). The primary outcome was the relative risk (RR) of acute kidney injury (AKI), irrespective of the AKI stage. The secondary outcome was the mean difference (MD) in the length of ICU and hospital stay, the RR of postoperative hemorrhage, and the MD in levels of methemoglobin. Trial sequential analysis (TSA) was performed for the primary outcome.
RESULTS
54 trials were assessed for eligibility and 5 studies (579 patients) were eligible for meta-analysis. NO was associated with reduced risk of AKI (RR 0.76, 95% confidential interval [CI], 0.62 to 0.93, I = 0%). In the subgroup analysis by NO initiation timing, NO did not decrease the risk of AKI when started at the end of CPB (RR 1.20, 95% CI 0.52-2.78, I = 0%). However, NO did significantly reduce the risk of AKI when started from the beginning of CPB (RR 0.71, 95% CI 0.54-0.94, I = 10%). We conducted TSA based on three trials (400 patients) using KDIGO criteria and with low risk of bias. TSA indicated a CI of 0.50-1.02 and an optimal information size of 589 patients, suggesting a lack of definitive conclusion. Furthermore, NO does not affect the length of ICU and hospital stay or the risk of postoperative hemorrhage. NO slightly increased the level of methemoglobin at the end of CPB (MD 0.52%, 95% CI 0.27-0.78%, I = 90%), but it was clinically negligible.
CONCLUSIONS
NO appeared to reduce the risk of postoperative AKI in patients undergoing CPB. Additional studies are required to ascertain the finding and further determine the dosage, timing and duration of NO administration.
PubMed: 31754841
DOI: 10.1186/s13613-019-0605-9 -
Journal of Gastroenterology and... Nov 2023Neoplastic polyp removal is important for colorectal cancer prevention. Endoscopists have proposed cold snare endoscopic mucosal resection (CS-EMR) as a solution to... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND AIM
Neoplastic polyp removal is important for colorectal cancer prevention. Endoscopists have proposed cold snare endoscopic mucosal resection (CS-EMR) as a solution to solve positive cutting edges and postoperative bleeding. However, many controversies regarding its specific performance in practice have been reported. The aim of this pooled analysis was to report the efficacy and safety of CS-EMR.
METHODS
PubMed/Medline, Embase, Google Scholar, and the Cochrane Library searched up to January 2022 to identify studies in which CS-EMR was performed for the removal of colorectal polyps measuring less than 20 mm. The primary outcome was the complete resection rate (CRR), and the secondary outcome was the rate of adverse events.
RESULTS
Eleven studies were included in the final analysis, which included 861 colorectal polyps. The overall CRR with CS-EMR was 96.3% (95% CI, 93.9-98.2%). The early and delayed bleeding rates of CS-EMR were 3.1% (95% CI, 1.2-5.5%) and 1.4% (95% CI, 0.6-2.4%), respectively. There were no statistical significances between CS-EMR and cold snare polypectomy (CSP) in terms of the CRR and adverse events, as well as CS-EMR and hot snare endoscopic mucosal resection (HS-EMR).
CONCLUSIONS
For resecting colorectal polyps measuring ≤20 mm, CS-EMR is an effective attempt. However, compared with CSP and HS-EMR, CS-EMR did not improve the efficiency and safety of polypectomy as expected. Multicenter randomized controlled trials are needed to compare CSP with CS-EMR in the resection of <10 mm polyps and HSP with CS-EMR in the resection of ≥10 mm polyps.
Topics: Humans; Colonic Polyps; Colonoscopy; Postoperative Hemorrhage; Colorectal Neoplasms; Endoscopic Mucosal Resection; Multicenter Studies as Topic
PubMed: 37608577
DOI: 10.1111/jgh.16308 -
Journal of Vascular Surgery Mar 2023To provide an updated systematic literature review summarizing current evidence on aortic neck dilatation (AND) after endovascular aortic aneurysm repair (EVAR) in... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To provide an updated systematic literature review summarizing current evidence on aortic neck dilatation (AND) after endovascular aortic aneurysm repair (EVAR) in patients with infrarenal abdominal aortic aneurysm.
METHODS
An extensive electronic search in major electronic databases was conducted between January 2000 and December 2021. Eligible for inclusion were observational studies that followed up with patients (n ≥ 20) undergoing EVAR with self-expanding endografts, for 12 or more months, evaluated AND with computed tomography angiography and provided data on relevant outcomes. The primary end point was the incidence of AND after EVAR, and the secondary end points were the occurrence of type Ia endoleak, stent graft migration, secondary rupture, and reintervention.
RESULTS
We included 34 studies with a total sample of 12,038 patients (10,413 men; median age, 71 years). AND was defined clearly in 18 studies, but significant differences in AND definition were evidenced. The pooled incidence of AND based on quantitative analysis of 16 studies with a total of 9201 patients (7961 men; median age, 72 years) was calculated at 22.9% (95% confidence interval [CI], 14.4-34.4) over a follow-up period ranging from 12 months to 14 years. The risk of a type Ia endoleak was significantly higher in AND patients compared with those without AND (odds ratio, 2.95; 95% CI, 1.10-7.93; P = .030). Similarly, endograft migration was more common in the AND group compared with the non-AND group (odds ratio, 5.95; 95% CI, 1.80-19.69; P = .004). The combined incidence of secondary rupture and reintervention did not differ significantly between the two groups, even though the combined effect was in favor of the non-AND group.
CONCLUSIONS
Proximal AND after EVAR is common and occurs in a large proportion of patients with infrarenal abdominal aortic aneurysm. AND can influence the long-term durability of proximal endograft fixation and is significantly related to adverse outcomes, often leading to reinterventions.
Topics: Male; Humans; Aged; Blood Vessel Prosthesis Implantation; Endoleak; Treatment Outcome; Dilatation; Risk Factors; Endovascular Procedures; Retrospective Studies; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis
PubMed: 35948244
DOI: 10.1016/j.jvs.2022.07.182 -
Clinical Otolaryngology : Official... Jan 2023To evaluate the analgesic and anti-haemorrhagic efficacy of platelet-rich plasma (PRP) among patients undergoing tonsillectomy. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To evaluate the analgesic and anti-haemorrhagic efficacy of platelet-rich plasma (PRP) among patients undergoing tonsillectomy.
DESIGN
A systematic review and meta-analysis of randomised controlled trials (RCTs).
SETTING
PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases were screened from inception until July 2021, and updated in December 2021.
PARTICIPANTS
Patients undergoing tonsillectomy.
MAIN OUTCOME MEASURES
The efficacy endpoints of postoperative pain and haemorrhage were summarised as standardised mean difference (SMD) and risk ratio (RR), respectively, with 95% confidence interval (CI).
RESULTS
Seven RCTs Seven RCTs were analysed, comprising a total of 392 patients. Risk of bias evaluation showed an overall high risk in one RCT, low risk in four RCTs and some concerns in two RCTs. The pooled results revealed that the mean postoperative pain score was significantly reduced in favour of the PRP group compared with the control group (SMD = -1.38, 95% CI [-1.91, -0.85], p < 0.001). Subgroup analysis showed the effect estimate was statistically significant for early postoperative pain (Day 0 to Day 3), without substantial difference between both groups on late postoperative pain (Days 5 and 7). Moreover, the rate of postoperative haemorrhage was significantly reduced in favour of the PRP group compared with the control group (RR = 0.16, 95% CI [0.05, 0.50], p = 0.001). Subgroup analysis showed the effect estimate was statistically significant for the rate of primary and secondary haemorrhage.
CONCLUSION
PRP was associated with significant reduction in postoperative pain and haemorrhage among patients undergoing tonsillectomy.
Topics: Humans; Tonsillectomy; Platelet-Rich Plasma; Analgesics; Pain, Postoperative; Postoperative Hemorrhage; Randomized Controlled Trials as Topic
PubMed: 36029195
DOI: 10.1111/coa.13977 -
Journal of Vascular Surgery Aug 2023To investigate the long-term reinterventions of thoracic endovascular repair (TEVAR) after blunt traumatic aortic injury. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To investigate the long-term reinterventions of thoracic endovascular repair (TEVAR) after blunt traumatic aortic injury.
METHODS
MEDLINE, EMBASE, and Cochrane databases were interrogated until June 2021. Inclusion criteria were blunt traumatic aortic injury treated with TEVAR and mean follow-up of more than 60 months. A systematic review was conducted and data were pooled using a random effects model of proportions applying the Freeman-Tukey transformation. Late reintervention was the primary outcome. Secondary outcomes were procedure-related complications (endoleak, in-stent thrombosis, occlusion, infolding/collapse, bird-beak, migration, and left arm claudication), overall and aortic-related mortality, and aortic diameter changes.
RESULTS
Eleven studies with a low quality assessment were included. Four hundred eight patients were collected and the 389 surviving more than 30 days were included. The mean follow-up was 8.2 years (95% confidence interval [CI], 5.7-10.8; I = 40.2%). Late reintervention was 2.1% (95% CI, 0.6-3.9; I = 0.0%; 11/389 cases) with 0.1% (95% CI, 0.0-1.2; I = 0.0%; 3/389) occurring after 5 years. Bird-beak was identified in 38.7% (95% CI, 16.4-63.6; I = 86.6%). Left arm claudication occurring after 30 days was 3.1% (95% CI, 0.1-8.6; I = 26.9%; 11/140 cases). In-stent thrombosis was 1.9% (95% CI, 0.1-5.2; I = 51.8%; 11/389 cases). Endoleak was 0.5% (95% CI, 0.0-1.9; I = 0.0%; 5/389 cases). Infolding, occlusion, and migration were reported in 2 of 389, 1 of 389, and 0 of 389 patients, respectively. Overall late survival was 95.6% (95% CI, 88.1-99.8; I = 84.7%; 358/389 patients) and only one patient accounted for aortic related mortality. The increase in proximal and distal aortic diameters was estimated at 2.7 mm (95% CI, 1.2-4.3; I = 0.0%) and 2.5 mm (95% CI, 1.1-3.9; I = 0.0%), respectively.
CONCLUSIONS
TEVAR demonstrates remarkably good long-term results and reinterventions are rarely required. Aortic reinterventions tend to occur within the first and after the fifth year.
Topics: Humans; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Aorta, Thoracic; Stents; Endoleak; Treatment Outcome; Endovascular Procedures; Retrospective Studies; Wounds, Nonpenetrating
PubMed: 36754248
DOI: 10.1016/j.jvs.2023.01.196 -
Clinical Interventions in Aging 2018Patients undergoing femoral fracture surgery frequently require blood transfusion. Tranexamic acid (TXA) has been widely used to decrease transfusion rate in joint... (Review)
Review
BACKGROUND
Patients undergoing femoral fracture surgery frequently require blood transfusion. Tranexamic acid (TXA) has been widely used to decrease transfusion rate in joint replacement surgery. Therefore, we conducted a systematic review to evaluate the efficacy and safety of TXA usage in femoral fracture surgery.
MATERIALS AND METHODS
Studies involving TXA usage in femoral fracture surgery were searched through four electronic databases. The end points included total blood loss, postoperative hemoglobin decline, transfusion rate, thromboembolic events, 90-day mortality, and operative time. The present study was performed following Cochrane Reviewers' Handbook and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was carried out by using Stata 14.0 software.
RESULTS
Eleven studies concerning intravenous (IV) application of TXA and three studies concerning topical administration of TXA were included. Twelve studies were randomized controlled trials (RCTs), and one was a retrospective cohort study. Regarding IV TXA, our paper indicated that the IV TXA group had less total blood loss (weighted mean difference [WMD] = -319.282, = 0.000), lower postoperative hemoglobin decline (WMD = -1.14, = 0.000) and lower transfusion rate (risk difference [RD] = -0.172, = 0.000). No significant differences were found in thromboembolic events (RD = 0.008, = 0.507), 90-day mortality (RD = 0.009, = 0.732) and operative time (WMD = -2.227, = 0.103). Regarding topical TXA, no significant differences were found in the transfusion rate (RD = -0.098, = 0.129), postoperative hemoglobin decline (WMD = -1.137, = 0.231), thromboembolic events (RD = -0.017, = 0.660) and operative time (WMD = -4.842, = 0.136).
CONCLUSION
Our meta-analysis demonstrated that both IV and topical application of TXA reduced transfusion rate in femoral fracture surgery. However, still further studies are needed to identify the optimal route of administration, TXA dosage and timing. In addition, high-quality RCTs with a large sample size are required to figure out the safety of TXA application, especially in the elderly, before its wide recommendation.
Topics: Administration, Intravenous; Administration, Topical; Antifibrinolytic Agents; Blood Loss, Surgical; Blood Transfusion; Femoral Fractures; Hemoglobins; Humans; Operative Time; Postoperative Hemorrhage; Thromboembolism; Tranexamic Acid
PubMed: 30233155
DOI: 10.2147/CIA.S163950 -
International Journal of Colorectal... May 2023The optimal technique for removing small colorectal polyps ranging from 5 to 10 mm in size remains uncertain. In order to compare the efficacy and adverse events... (Meta-Analysis)
Meta-Analysis Review
The efficacy and safety of cold snare versus hot snare polypectomy for endoscopic removal of small colorectal polyps: a systematic review and meta-analysis of randomized controlled trials.
PURPOSE
The optimal technique for removing small colorectal polyps ranging from 5 to 10 mm in size remains uncertain. In order to compare the efficacy and adverse events between cold snare polypectomy (CSP) and hot snare polypectomy (HSP) for removing small polyps, we conducted a systematic review and meta-analysis of available randomized controlled trials.
METHODS
We conducted a comprehensive search of MEDLINE, EMBASE, and the Cochrane Library databases from 1998 to May 2023 to identify randomized controlled trials that evaluated the efficacy and safety of cold snare polypectomy (CSP) and hot snare polypectomy (HSP) for resecting small colorectal polyps. The primary outcome measure was the incomplete resection rate (IRR).
RESULTS
Seven studies that met our study criteria, with a total of 3178 included polyps, were included in our analysis. The incomplete resection rate (IRR) was found to be significantly higher in the CSP group compared to the HSP group (risk ratio [RR] 1.57 [1.17-2.11], P = 0.003). Although the CSP group had a higher local recurrence rate than the HSP group, the difference was not statistically significant (RR: 3.98 [0.66-23.84], P = 0.13). The polyp retrieval rates were not significantly different between the two groups (RR: 1.00 [0.99-1], P = 0.22). Perforation was not reported or mentioned in any of the seven studies. The overall immediate bleeding rate was significantly higher in the CSP group than the HSP group (RR: 2.26 [1.63-3.14], P < 0.001), but immediate postpolypectomy bleeding requiring additional intervention was similar between the groups (RR: 1.08 [0.54-2.17], P = 0.82). The delayed bleeding rate (RR: 0.83 [0.45-1.55], P = 0.56) and specific polypectomy time (RR: -0.46 [-1.05-0.12], P = 0.12) were also similar between the groups.
CONCLUSIONS
The meta-analysis shows a significantly higher IRR for CSP compared with HSP when removing small polyps.
Topics: Humans; Colonic Polyps; Colonoscopy; Randomized Controlled Trials as Topic; Microsurgery; Postoperative Hemorrhage
PubMed: 37204495
DOI: 10.1007/s00384-023-04429-2 -
Journal of the American College of... May 2016Management of perioperative antiplatelet medications in gastrointestinal (GI) surgery is challenging. The risk of intraoperative and postoperative bleeding is associated... (Review)
Review
BACKGROUND
Management of perioperative antiplatelet medications in gastrointestinal (GI) surgery is challenging. The risk of intraoperative and postoperative bleeding is associated with perioperative use of antiplatelet medication. However, cessation of these drugs may be unsafe for patients who are required to maintain antiplatelet use due to cardiovascular conditions. The objective of this systematic review was to compare the risk of intraoperative or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy (aspirin, clopidogrel, or dual therapy) with the risk among those not taking continuous antiplatelet medication.
STUDY DESIGN
We reviewed articles published between January 2000 and July 2015 from the Medline Ovid and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Studies involving any GI procedures were included if the articles met our inclusion criteria (listed in Methods). The following key words were used for the search: clopidogrel, Plavix, aspirin, antiplatelet, bleeding, hemorrhage, and digestive system surgical procedures. Quality of the studies was assessed, depending on their study design, using the Newcastle-Ottawa score or the Cochrane Collaboration's tool for assessing risk of bias.
RESULTS
Twenty-two studies were eligible for inclusion in the systematic review. Five showed that the risk of intraoperative bleeding or postoperative bleeding among patients who had GI surgery while on continuous antiplatelet therapy was higher compared that for those not on continuous therapy. The remaining 17 studies reported that there was no statistically significant difference in the risks of bleeding between the continuous antiplatelet therapy group and the group without continuous antiplatelet therapy.
CONCLUSIONS
The risk of bleeding associated with GI procedures in patients receiving antiplatelet therapy was not significantly higher than in patients with no antiplatelet or interrupted antiplatelet therapy.
Topics: Digestive System Surgical Procedures; Endoscopy, Digestive System; Herniorrhaphy; Humans; Intraoperative Complications; Platelet Aggregation Inhibitors; Postoperative Complications; Postoperative Hemorrhage; Quality Assurance, Health Care; Risk Assessment
PubMed: 27016908
DOI: 10.1016/j.jamcollsurg.2016.01.053