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European Spine Journal : Official... Sep 2020Systematic review, meta-analysis, evidence synthesis. (Meta-Analysis)
Meta-Analysis Review
STUDY DESIGN
Systematic review, meta-analysis, evidence synthesis.
OBJECTIVES
To analyse the literature evidence available to support the usage of wound drain in various scenarios of spine surgery and provide an evidence summary on the surgical practice.
MATERIALS AND METHODS
We conducted independent and duplicate electronic database searches adhering to PRISMA guidelines in PubMed, Embase, and Cochrane Library till April 2020. Quality appraisal was done as per Cochrane ROB tool, and evidence synthesis was done as per GRADE approach. Five domains of spine surgery with associated key questions were identified. Evidence tables were generated for each question and critical appraisal done as per the GRADE approach.
RESULTS
Twenty-three studies (9-RCTs, 4-prospective studies, 10-retrospective studies) were included. Analysis of studies in cervical spine either by anterior or posterior approach and single/multilevel thoracolumbar spinal surgeries did not show any evidence of reduction in surgical site infection (SSI) or haematoma formation with the use of drain. Deformity correction surgeries and surgeries done for trauma or tumour involving spine also did not find any added benefit from the use of wound drains despite increasing the total blood loss.
CONCLUSION
Evidence from this review suggests that routine use of drain in various domains of spine surgery does not reduce the risk of SSI and their absence did not increase the risk of haematoma formation. The current best evidence is presented with its limitations. High-quality studies to address their use in spine surgeries in cervical, trauma, and tumour domains are required to further strengthen the evidence synthesised from available literature.
Topics: Drainage; Humans; Prospective Studies; Retrospective Studies; Spine; Surgical Wound Infection
PubMed: 32700123
DOI: 10.1007/s00586-020-06540-2 -
Journal of Surgical Education 2016To determine whether outcomes are different when surgery is performed by resident or attending surgeons, and which variables may affect outcomes. (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVE
To determine whether outcomes are different when surgery is performed by resident or attending surgeons, and which variables may affect outcomes.
DESIGN
MEDLINE, EMBASE, and the Cochrane Library were searched from inception to May 2014 alongside the bibliographies of all included or relevant studies. Any study comparing outcomes from surgery performed by resident vs attending surgeons was eligible for inclusion. The main outcome measures were surgical complications (classified by Clavien-Dindo grade), death, operative time, and length of stay. Data were extracted independently by 2 authors and analyzed using the random-effects model.
RESULTS
The final analysis included 182 eligible studies that enrolled 141 555 patients. Resident performed surgery took longer by 10.2 minutes (95% confidence interval (CI): 8.38-11.95), and had more Clavien-Dindo grade 1 (rate ratio = 1.14, 95% CI: 1.02-1.29) and grade 3a complications (rate ratio = 1.22, 95% CI: 1.04-1.44). Resident performed surgery resulted in fewer deaths (risk ratio = 0.83, 95% CI: 0.70-0.999) with a shorter length of stay of -0.49 days (95% CI: -0.77 to -0.21). Significant heterogeneity was present in 7 of 10 outcomes, which persisted during multiple subgroup analyses.
CONCLUSIONS
Resident performed surgery appears to be safe in carefully selected patients. The significant amount of heterogeneity present in the study outcomes prevents generalizability of these results to specific clinical contexts.
Topics: Clinical Competence; Education, Medical, Graduate; Hospital Mortality; Humans; Internship and Residency; Length of Stay; Medical Staff, Hospital; Operative Time; Outcome and Process Assessment, Health Care; Patient Safety; Patient Selection; Postoperative Complications; Surgical Procedures, Operative
PubMed: 26966079
DOI: 10.1016/j.jsurg.2016.01.002 -
Surgical Infections Apr 2016Surgical site infection (SSI) is one of the main causes of morbidity and death after surgical intervention. The use of physical barriers, including gloves, drapes, and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical site infection (SSI) is one of the main causes of morbidity and death after surgical intervention. The use of physical barriers, including gloves, drapes, and gowns to reduce SSI after abdominal surgery is long-standing practice. The aim of this systematic review and meta-analysis was to determine the efficacy of ring incision retractors in reducing the risk of SSI in abdominal surgery.
METHODS
PubMed, CINAHL, the Cochrane randomized controlled trials (RCTs) Central Register, and the ISRCTN registry were searched for RCTs in which ring retractors were utilized to reduce SSI in abdominal surgery. The PRISMA guidelines and RevMan 5.3 were used for study selection and analysis. Additional subgroup analyses were performed, including trials using incision class (clean, clean-contaminated contaminated, and dirty) and trials that used the U.S. Centers for Disease Control and Prevention's SSI definition in their protocol.
RESULTS
A total of 19 RCTs inclusive of 4,229 patients were included. The utility of ring retractors in reducing SSI was suggested by an overall risk ratio of 0.62 (95% confidence interval 0.48-0.81). However, study heterogeneity caused by differences in effect size between individual RCTs, the non-standardized utilization of concomitant measures to reduce SSI, and an overall lack of high-quality trials was found.
CONCLUSION
A reduction in SSI incidence with the use of ring retractors is suggested by the findings. However, this result must be treated with caution because in addition to some old trials poor quality and the large number of factors affecting SSI, there were substantial differences between trials in effect sizes in statistical heterogeneity. Further RCTs are needed to confirm this provisional finding.
Topics: Abdomen; Humans; Incidence; Randomized Controlled Trials as Topic; Surgical Procedures, Operative; Surgical Wound Infection
PubMed: 26784527
DOI: 10.1089/sur.2015.145 -
Physical Therapy Mar 2023Preoperative exercise (prehabilitation) is commonly used as a method to reduce pain and improve function postoperatively. The purpose of this systematic review was to... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Preoperative exercise (prehabilitation) is commonly used as a method to reduce pain and improve function postoperatively. The purpose of this systematic review was to determine therapeutic benefits of preoperative exercise on postoperative pain, function, quality of life (QOL), and risk of complications across various types of surgeries.
METHODS
Three electronic databases were used to perform a literature search. Full articles with randomized designs comparing a preoperative exercise program vs no formal program were included. The primary outcome was postoperative pain. QOL, function, and postoperative complications were analyzed as secondary outcomes. The primary meta-analysis was performed in those with joint replacement surgery because there were only 5 with other surgical types.
RESULTS
A total of 28 articles were included, of which 23 were from individuals with total joint replacement surgery. Preoperative exercise resulted in lower pain ≤2 months and 3 to 5 months after joint replacement surgery with a moderate standardized mean difference (95% CI at <2 months = -0.34 [-0.59 to -0.09]; at 3 to 5 months = -0.41 [-0.70 to -0.11]) compared with nonexercised controls. However, ≥6 months after joint replacement surgery, preoperative exercise groups showed no significant differences in postoperative pain (standardized mean difference = -0.17 [-0.35 to 0.01]) compared with nonexercised controls. QOL and subjective and objective function were improved ≤2 months after joint replacement surgery but were not different ≥6 months post-surgery. Reduction in risk of postoperative complications was favored with preoperative exercise.
CONCLUSION
Preoperative exercise has a modest effect on postoperative pain, function, and quality of life within the first 6 months after surgery and reduces the risk of developing postoperative complications in individuals undergoing joint replacement surgery. The effect of preoperative exercise on other surgery types is inconclusive.
IMPACT
This systematic review supports using preoperative exercise to improve pain and function outcomes for those with joint replacement surgery.
Topics: Humans; Quality of Life; Preoperative Exercise; Preoperative Care; Arthroplasty, Replacement, Knee; Pain, Postoperative; Postoperative Complications
PubMed: 37172124
DOI: 10.1093/ptj/pzac169 -
World Journal of Surgery Mar 2024Worldwide, ERAS Society guidelines have ushered in a new era of perioperative care. The purpose of this systematic review is to compare published core elements and...
Enhanced recovery after surgery (ERAS ) Society abdominal and thoracic surgery recommendations: A systematic review and comparison of guidelines for perioperative and pharmacotherapy core items.
INTRODUCTION
Worldwide, ERAS Society guidelines have ushered in a new era of perioperative care. The purpose of this systematic review is to compare published core elements and pharmacotherapy recommendations embedded within ERAS Society abdominal and thoracic surgery (ATS) guidelines. Determining whether a consensus exists for pharmacological core items would make future guideline preparation for similar surgeries more standardized and could improve patient care by reducing unnecessary protocol variations.
METHODS
From the ERAS Society website as of May 2023, 16 current ERAS published ATS guidelines were included in the analysis to determine consensus and differing statements regarding each ERAS perioperative and pharmacotherapy-related item. The aims were to (a) determine whether a consensus for each item could be derived, (b) identify gaps in ERAS protocol development, and (c) propose potential research directions for addressing the identified gaps in the literature.
RESULTS
Core items with consensus included: preoperative smoking and alcohol cessation; avoiding bowel reparation and fasting; multimodal preanesthetic, perioperative analgesia, and postoperative nausea and vomiting regimens; low molecular weight heparins for in-hospital and at-home venous thromboembolism prophylaxis; antibiotic prophylaxis; skin preparation; goal-directed perioperative fluid management with balanced crystalloids; perioperative nutrition care; ileus prevention with peripherally-acting mu receptor antagonists; and glucose control.
CONCLUSION
While consensus was found for aspects of 21 current ERAS guideline core items related to pharmacotherapy choice, details related to doses, regimen, timing of administration as well as unique aspects pertaining to specific surgeries remain to be researched and harmonized to promote guideline consistency and further optimize patient outcomes.
Topics: Humans; Enhanced Recovery After Surgery; Perioperative Care; Postoperative Nausea and Vomiting; Thoracic Surgery; Thoracic Surgical Procedures; Practice Guidelines as Topic
PubMed: 38348514
DOI: 10.1002/wjs.12101 -
Updates in Surgery Jun 2017Intraoperative neuromonitoring (IONM) has proven effective for intraoperative verification of RLN function in the conventional thyroid surgery. However, no studies have... (Review)
Review
Intraoperative neuromonitoring (IONM) has proven effective for intraoperative verification of RLN function in the conventional thyroid surgery. However, no studies have performed a systematic evidence-based assessment of this novel health technology in endoscopic and robotic thyroidectomy. Evidence-based criteria were used in a systematic review of relevant literature for years 2000-2015. Four electronic databases (CENTRAL, MEDLINE, Cochrane and EMBASE) were used to retrieve relevant reports published from January 1, 2000 to September 1, 2016. The search terms included "endoscopic thyroidectomy", "robotic thyroidectomy", "IONM", "continuous IONM (CIONM)", "neural monitoring", "recurrent laryngeal nerve monitoring", and "superior laryngeal monitoring". The following data were retrieved from eligible studies of patients undergoing endoscopic or robotic thyroidectomy: objective of study, design and setting of study, population, intervention examined, quality of data, follow-up and dropout rate, risk of bias, and outcomes assessed. Of 160 studies retrieved, only 9 (5%) studies used IONM. Eight studies reported 522 nerve at risk (NAR) with IONM. Only three were prospective randomized studies. Reports of IONM endoscopic and robotic procedures included their use for re-surgery and use in both benign and malignant cases. None of the IONM endoscopic procedures involved bilateral palsy. Two studies reported the use of a staged strategy. The rates of recurrent laryngeal palsy were 0-3.6% for transient and 0-0.4% for permanent. Only 30% of the studies performed vagus nerve stimulation, and only 25% performed superior laryngeal nerve monitoring. In addition to the use of IONM as an assistive technology for navigating the anatomy in challenging procedures such as endoscopic and robotic thyroidectomy, IONM has potential use as a routine adjunct to the conventional video-assisted nerve identification in thyroidectomy.
Topics: Endoscopy; Humans; Monitoring, Intraoperative; Recurrence; Recurrent Laryngeal Nerve Injuries; Reoperation; Robotic Surgical Procedures; Thyroid Diseases; Thyroidectomy
PubMed: 28439772
DOI: 10.1007/s13304-017-0442-z -
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 -
British Journal of Anaesthesia Nov 2013Regional anaesthesia may reduce the risk of persistent (chronic) pain after surgery, a frequent and debilitating condition. We compared regional anaesthesia vs... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Regional anaesthesia may reduce the risk of persistent (chronic) pain after surgery, a frequent and debilitating condition. We compared regional anaesthesia vs conventional analgesia for the prevention of persistent postoperative pain (PPP).
METHODS
We searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and CINAHL from their inception to May 2012, limiting the results to randomized, controlled, clinical trials (RCTs), supplemented by a hand search in conference proceedings. We included RCTs comparing regional vs conventional analgesia with a pain outcome at 6 or 12 months. The two authors independently assessed methodological quality and extracted data. We report odds ratios (ORs) with 95% confidence intervals (CIs) as our summary statistic based on random-effects models. We grouped studies according to surgical interventions.
RESULTS
We identified 23 RCTs. We pooled data from 250 participants in three trials after thoracotomy with outcomes at 6 months. Data favoured epidural anaesthesia for the prevention of PPP with an OR of 0.33 (95% CI 0.20-0.56). We pooled two studies investigating paravertebral block for breast cancer surgery; pooled data of 89 participants with outcomes ≈ 6 months favoured paravertebral block with an OR of 0.37 (95% CI 0.14-0.94). Adverse effects were reported sparsely.
CONCLUSIONS
Epidural anaesthesia and paravertebral block, respectively, may prevent PPP after thoracotomy and breast cancer surgery in about one out of every four to five patients treated. Small numbers, performance bias, attrition, and incomplete outcome data especially at 12 months weaken our conclusions.
Topics: Anesthesia, Conduction; Anesthesia, Epidural; Chronic Pain; Data Interpretation, Statistical; Follow-Up Studies; Humans; Nerve Block; Odds Ratio; Pain, Postoperative; Publication Bias; Randomized Controlled Trials as Topic; Surgical Procedures, Operative; Treatment Outcome
PubMed: 23811426
DOI: 10.1093/bja/aet213 -
World Journal of Surgery Jan 2015Venous thromboembolism (VTE) is a condition that has always been perceived to be rare in Asia. The aim of this systematic review was to gather the current available... (Review)
Review
BACKGROUND
Venous thromboembolism (VTE) is a condition that has always been perceived to be rare in Asia. The aim of this systematic review was to gather the current available evidence on the incidence of VTE in this population. A secondary aim was to assess the efficacy of pharmacological prophylaxis, and hence determine its role, in the Asian population.
METHODS
A comprehensive literature search was performed using MEDLINE, Embase, and the Cochrane Database of Systematic Reviews in June 2014. Articles found using search terms related to venous thromboembolism (VTE), Asian countries and general surgery procedures and pathologies were screened using the following inclusion criteria: (1) either the population studied was primarily Asian or the study was conducted in an Asian country, (2) the subjects studied underwent a major gastrointestinal or other general surgery procedure, (3) the primary outcome was the incidence of deep vein thrombosis (DVT) or pulmonary embolus (PE), and (4) secondary outcomes assessed included mortality and complications due to the VTE or prophylaxis against VTE.
RESULTS
Fourteen publications with a total of 11,218 patients were analyzed. Nine of the fourteen were observational studies, with half being prospective in nature. There were five interventional studies of which two were randomized controlled trials. Among the observational studies, the median (range) incidence of above-knee DVT was 0.08 % (0-2.9 %), while the median (range) incidence of PE was 0.18 % (0-0.58 %). The rates of DVT in the control groups were reported to be between 0 and 7.4 %, while the incidence of PE in the control groups ranged from 0 to 1.9 %. Analysis of the comparative studies revealed that the incidence of bleeding-related complications varied from 0 to 18.1 % in the low-molecular-weight heparin (LMWH) group compared to 0-7.5 % in the control group. The difference in minor bleeding complications between the LMWH group and the control group was found to be statistically significant.
CONCLUSION
Data from this systematic review suggest that the risk of VTE in Asian general surgery patients is low, even in the context of risk factors typically regarded as high risk.
Topics: Adult; Aged; Anticoagulants; Asia; Asian People; Female; Heparin, Low-Molecular-Weight; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Risk Factors; Surgical Procedures, Operative; Venous Thrombosis
PubMed: 25189450
DOI: 10.1007/s00268-014-2763-0 -
International Journal of Gynaecology... Feb 2017The value of tranexamic acid (TA) treatment as bleeding prophylaxis in major uterine surgery is unclear. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The value of tranexamic acid (TA) treatment as bleeding prophylaxis in major uterine surgery is unclear.
OBJECTIVES
To evaluate the antihemorrhagic effect of prophylactic TA treatment in major benign uterine surgery.
SEARCH STRATEGY
PubMed, Embase, Cochrane Library, and Web of Science were searched from 1980 to 2015 without language restriction using search terms related to major uterine surgery combined with TA.
SELECTION CRITERIA
Randomized controlled trials comparing prophylactic TA with placebo or no intervention in women undergoing elective major benign uterine surgery.
DATA COLLECTION AND ANALYSIS
Basic information and outcomes were collected and meta-analyses performed.
MAIN RESULTS
Sixteen trials were included, with five trials considered to have an overall low risk of bias. In cesarean delivery, TA significantly reduced intraoperative bleeding (mean -136 mL, 95% confidence interval [CI] -189 to -83), blood loss of more than 1000 mL (relative risk 0.38, 95% CI 0.18-0.81), and blood transfusion (relative risk 0.32, 95% CI 0.17-0.59). In abdominal myomectomy, TA also significantly reduced intraoperative bleeding (mean -251 mL, 95% CI -391 to -110).
CONCLUSIONS
Prophylactic TA treatment significantly reduced operative bleeding in women undergoing elective cesarean delivery or abdominal myomectomy. Additional randomized trials with low risk of bias are needed.
Topics: Antifibrinolytic Agents; Blood Loss, Surgical; Blood Transfusion; Cesarean Section; Female; Gynecologic Surgical Procedures; Humans; Pregnancy; Randomized Controlled Trials as Topic; Tranexamic Acid
PubMed: 28099726
DOI: 10.1002/ijgo.12047