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British Journal of Neurosurgery Aug 2022Endoscopic endonasal surgery (EES) is one of the preferred options for skull base pathologies. Cerebrospinal fluid (CSF) leak is a significant complication of EES and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Endoscopic endonasal surgery (EES) is one of the preferred options for skull base pathologies. Cerebrospinal fluid (CSF) leak is a significant complication of EES and neurosurgeons have proposed various reconstructive strategies to decrease this morbidity. We describe and compare the efficacy of these strategies.
METHODS
We searched PubMed, Cochrane Library, and Web of Science for publications between 1990 and November 2019. We defined a reconstruction hierarchy of seven levels from inside to outside: fat graft, intracranial intradural layer (inlay), intracranial extradural layer (onlay), buttress, mucosal flap, nasal packing and lumbar drainage. A single-arm analysis was performed for the primary outcome of CSF leak rate.
RESULTS
Of 3641 records identified, 48 studies met the inclusion criteria. Pituitary tumors had lower postoperative CSF leak rate than other diseases (1.8% vs. 6.5%, RD = -4.7% [-7.1%, -2.1%]). In high CSF flow group, the post-operative leak rate was reduced by application of mucosal flap (4.3% vs. without mucosal flap at 12.8%, RD = -8.5% [-15.1%, -1.9%]). The use of inlay showed potential of decreasing the post-operative leak rate (5.0% vs. 7.2%, RD = -2.2% [-7.7%, 3.3%]). In low CSF flow group, tampon was better than balloon for nasal packing (1.0% vs. 10.5%, RD = -9.5% [-16.5%, -2.4%]).
CONCLUSIONS
Mucosal flap and inlay for high-flow intraoperative CSF leak and tampon (compared with balloon) for low-flow intraoperative CSF leak, improved the postoperative CSF leak rate. Further studies are required to establish more robust evidence.
Topics: Cerebrospinal Fluid Leak; Endoscopy; Humans; Postoperative Complications; Plastic Surgery Procedures; Retrospective Studies; Skull Base; Surgical Flaps
PubMed: 33475004
DOI: 10.1080/02688697.2020.1849548 -
European Journal of Orthopaedic Surgery... Jul 2021Tourniquet use in lower limb fracture surgery may reduce intra-operative bleeding, improve surgical field of view and reduce length of procedure. However, tourniquets... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Tourniquet use in lower limb fracture surgery may reduce intra-operative bleeding, improve surgical field of view and reduce length of procedure. However, tourniquets may result in pain and the production of harmful metabolites cause complications or affect functional outcomes. This systematic review aimed to compare outcomes following lower limb fracture surgery performed with or without tourniquet.
METHODS
We searched databases for RCTs comparing lower limb fracture surgery performed with versus without tourniquet reporting on outcomes pain, physical function, health-related quality of life, complications, cognitive function, blood loss, length of stay, length of procedure, swelling, time to union, surgical field of view, volume of anaesthetic agent, biochemical markers of inflammation and injury, and electrolyte and acid-base balance. Random-effects meta-analysis was performed. PROSPERO ID CRD42020209310.
RESULTS
Six RCTs enabled inclusion of 552 procedures. Pooled analysis demonstrated that tourniquet use reduced length of procedure by 6 minutes (95% CI -10.12 to -1.87; p < 0.010). We were unable to exclude increased harms from tourniquet use. Pooled analysis showed post-operative pain score was higher in tourniquet group by 12.88 on 100-point scale (95% CI -1.25-27.02; p = 0.070). Risk differences for wound infection, deep venous thrombosis and re-operation were 0.06 (95% CI -0.00-0.12; p = 0.070), 0.05 (95% CI -0.02-0.11; p = 0.150) and 0.03 (95% CI -0.03-0.09; p = 0.340).
CONCLUSION
Tourniquet use was associated with a reduced length of procedure. It is possible that tourniquets also increase incidence of important complications, but the data are too sparse to draw firm conclusions. Methodological weaknesses of the included RCTs prevent any solid conclusions being drawn for outcomes investigated. Further studies are required to address these limitations.
Topics: Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Humans; Lower Extremity; Pain, Postoperative; Quality of Life; Tourniquets
PubMed: 33792771
DOI: 10.1007/s00590-021-02957-7 -
World Neurosurgery Apr 2021In this study, we aimed to compare the minimally invasive surgery (MIS) instrumented fusion ± decompression versus conventional open surgery (COS) instrumented fusion... (Comparative Study)
Comparative Study Meta-Analysis
Minimal Invasive Surgery Instrumented Fusion versus Conventional Open Surgical Instrumented Fusion for the Treatment of Spinal Metastases: A Systematic Review and Meta-analysis.
OBJECTIVE
In this study, we aimed to compare the minimally invasive surgery (MIS) instrumented fusion ± decompression versus conventional open surgery (COS) instrumented fusion ± decompression for the treatment of spinal metastases.
METHODS
We performed a systematic literature search through PubMed, Scopus, Europe PMC (PubMed Central), and Cochrane Central Database using the keywords "minimal invasive surgery" OR "minimally invasive surgery" OR "mini-open" AND "conventional open surgery" OR "traditional open surgery" OR "open surgery" AND "spinal metastasis". The outcomes of interest were complications, neurologic improvement, length of stay, intraoperative blood loss, transfusion rate, and operative duration.
RESULTS
There were a total of 8 studies comprising 486 patients. Complications were less frequent in MIS compared with COS (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.30-0.84; P = 0.01; I = 0%). Major complications related to surgery were less in the MIS group (OR, 0.42; 95% CI, 0.21-0.84; P = 0.01; I = 0%). The rate of neurologic improvement was similar in both groups (OR, 1.01; 95% CI, 0.64-1.59; P = 0.95; I = 0%). MIS was associated with less blood loss (mean difference, -690.00 mL; 95% CI, -888.31 to -491.69; P < 0.001; I = 56%), and lower transfusion rate compared with COS (OR, 0.27; 95% CI, 0.11-0.66; P = 0.004; I = 50%). Length of surgery was similar in both groups (mean difference, -12.49 minutes; 95% CI, -45.93 to 20.95; P = 0.46; I = 86%). MIS resulted in shorter length of stay compared with COS (mean difference -3.58 days; 95% CI, -6.90 to -0.26; P = 0.03; I = 89%).
CONCLUSIONS
MIS was associated with lower complications, blood loss, transfusion rate, and shorter length of stay with a similar rate of neurologic improvement and length of surgery compared with COS.
Topics: Blood Loss, Surgical; Blood Transfusion; Bone Screws; Decompression, Surgical; Humans; Internal Fixators; Length of Stay; Minimally Invasive Surgical Procedures; Postoperative Complications; Procedures and Techniques Utilization; Spinal Fusion; Spinal Neoplasms; Treatment Outcome
PubMed: 33418123
DOI: 10.1016/j.wneu.2020.12.130 -
World Journal of Surgery Oct 2017The safety of anticoagulation interruption in patients requiring surgical or invasive procedures remains unclear. We thus performed a systematic review and meta-analyses... (Meta-Analysis)
Meta-Analysis Review
Safety of Anticoagulation Interruption in Patients Undergoing Surgery or Invasive Procedures: A Systematic Review and Meta-analyses of Randomized Controlled Trials and Non-randomized Studies.
BACKGROUND
The safety of anticoagulation interruption in patients requiring surgical or invasive procedures remains unclear. We thus performed a systematic review and meta-analyses of randomized controlled trials (RCTs) and non-randomized studies (NRS).
METHODS
MEDLINE, Embase and Central databases were searched to March 2017 without date or language restrictions. We considered RCTs and NRS comparing anticoagulation interruption with any anticoagulation (continuation or heparin bridging) in adult surgical patients taking oral anticoagulation. Data were independently extracted. The quality of the evidence was assessed following recommendations from the Cochrane collaboration (GRADE approach). Risk ratios were calculated for 30-day events: thromboembolic (TE) events, major bleeding and mortality. Additional analyses explored the effects of different anticoagulation strategies.
RESULTS
Twelve reports were included: 4 RCTs (2190 participants) and 8 NRS (18993 participants). Trials included mostly participants with atrial fibrillation. Interrupting anticoagulation did not seem to increase TE events (RR 0.65, 95% CI [0.33, 1.30]-4 studies, 2190 participants) and resulted in less bleeding (RR 0.41, 95% CI [0.22, 0.78]-3 studies, 2126 participants) compared to anticoagulation continuation or heparin bridging. The GRADE assessment was moderate. Similar results were found in non-randomized studies, but the quality of the evidence was low. Possible strategy-specific effects were identified: forgoing heparin bridging seemed beneficial, but these effects were less clear with other strategies.
CONCLUSION
Interrupting anticoagulation in patients requiring invasive procedures did not seem to result in harm and protected against major bleeding. Uncertainty remains regarding the safety of this strategy in indications other than atrial fibrillation and in moderate- to high-risk surgery.
STUDY REGISTRATION
http://www.en.anaesthesie.usz.ch/research/Pages/Study-protocols.aspx.
Topics: Anticoagulants; Atrial Fibrillation; Deprescriptions; Hemorrhage; Heparin; Humans; Non-Randomized Controlled Trials as Topic; Randomized Controlled Trials as Topic; Surgical Procedures, Operative; Thromboembolism
PubMed: 28608011
DOI: 10.1007/s00268-017-4072-x -
Health Technology Assessment... Jan 2008To determine whether there is a level of methicillin-resistant Staphylococcus aureus (MRSA) prevalence at which a switch from non-glycopeptide to glycopeptide... (Review)
Review
OBJECTIVES
To determine whether there is a level of methicillin-resistant Staphylococcus aureus (MRSA) prevalence at which a switch from non-glycopeptide to glycopeptide antibiotics for routine prophylaxis is indicated in surgical environments with a high risk of MRSA infection.
DATA SOURCES
Major electronic databases were searched up to September 2005.
REVIEW METHODS
The effectiveness review included controlled clinical trials comparing a glycopeptide with an alternative antibiotic regimen that reported effectiveness and/or adverse events. Controlled observational studies were also included for adverse events. The cost-effectiveness review included economic evaluations comparing glycopeptide prophylaxis with any alternative comparator. Study validity was assessed using standard checklists. The supplementary economic reviews assessed evaluations of non-glycopeptide antibiotic prophylaxis; evaluations where antibiotic resistance is a problem; methods of modelling resistance in infectious diseases; and developing a conceptual framework. An indicative decision analytic model was developed to compare vancomycin with a cephalosporin and with a combination of vancomycin and cephalosporin, using hip arthroplasty as an exemplar. Available data on, for example, surgical site infection (SSI) rates, MRSA rates, effectiveness of the antibiotics, were incorporated into the model. Costs were estimated from the perspective of the NHS.
RESULTS
The effectiveness review included 16 randomised controlled trials, with a further three studies included for adverse events only. There was no evidence that glycopeptides were more effective than non-glycopeptides in preventing SSIs. Most of the trials did not report either the baseline prevalence of MRSA at the participating surgical units or MRSA infections as an outcome. The cost-effectiveness review included five economic evaluations of glycopeptide prophylaxis. Only one study incorporated health-related quality of life and undertook a cost-utility analysis. None of the studies was undertaken in the UK and none explicitly modelled antibiotic resistance. The supplementary reviews provided few insights into how to assess cost-effectiveness in the context of resistance. No studies modelled cost-effectiveness alongside epidemiological models of resistance. There was little information regarding the impact of surgical infections on costs post-discharge and patient quality of life. The lack of available clinical evidence limited the development of the cost-effectiveness model and meant that the modelling could only be indicative in nature. The model can be used to show the threshold baseline risk at which the use of vancomycin as prophylaxis might be cost-effective (the model did not include teicoplanin). The indicative model suggests that the baseline risk of MRSA can be fairly modest at below the national average and it would still appear cost-effective to use glycopeptide prophylaxis. The model indicates that the use of glycopeptides as a form of prophylaxis in addition to a treatment for MRSA infections is unlikely to decrease the total usage and hence reduce the risk of future problems with glycopeptide-resistant bacteria.
CONCLUSIONS
There is insufficient evidence to determine whether there is a threshold prevalence of MRSA at which switching from non-glycopeptide to glycopeptide antibiotic prophylaxis might be clinically effective and cost-effective. Future research needs to address the complexities of decision-making relating to the prevention of MRSA and infection control in general. Research including evidence synthesis and decision modelling comparing a full range of interventions for infection control, which extends to other infections, not just MRSA, is needed. A long-term research programme to predict the pattern of drug resistance and its implications for future costs and health is also needed.
Topics: Anti-Bacterial Agents; Antibiotic Prophylaxis; Cephalosporins; Cost-Benefit Analysis; Drug Utilization; Glycopeptides; Humans; Methicillin Resistance; Models, Econometric; Quality of Life; Randomized Controlled Trials as Topic; Staphylococcal Infections; Surgical Procedures, Operative; Surgical Wound Infection
PubMed: 18093447
DOI: 10.3310/hta12010 -
The British Journal of Surgery Sep 2013Local anaesthetic wound infiltration techniques reduce opiate requirements and pain scores. Wound catheters have been introduced to increase the duration of action of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Local anaesthetic wound infiltration techniques reduce opiate requirements and pain scores. Wound catheters have been introduced to increase the duration of action of local anaesthetic by continuous infusion. The aim was to compare these infiltration techniques with the current standard of epidural analgesia.
METHODS
A meta-analysis of randomized clinical trials (RCTs) evaluating wound infiltration versus epidural analgesia in abdominal surgery was performed. The primary outcome was pain score at rest after 24 h on a numerical rating scale. Secondary outcomes were pain scores at rest at 48 h, and on movement at 24 and 48 h, with subgroup analysis according to incision type and administration regimen(continuous versus bolus), opiate requirements, nausea and vomiting, urinary retention, catheter-related complications and treatment failure.
RESULTS
Nine RCTs with a total of 505 patients were included. No differences in pain scores at rest 24 h after surgery were detected between epidural and wound infiltration. There were no significant differences in pain score at rest after 48 h, or on movement at 24 or 48 h after surgery. Epidural analgesia demonstrated a non-significant a trend towards reduced pain scores on movement and reduced opiate requirements. There was a reduced incidence of urinary retention in the wound catheter group.
CONCLUSION
Within a heterogeneous group of RCTs, use of local anaesthetic wound infiltration was associated with pain scores comparable to those obtained with epidural analgesia. Further procedure-specific RCTs including broader measures of recovery are recommended to compare the overall efficacy of epidural and wound infiltration analgesic techniques.
Topics: Abdomen; Analgesia, Epidural; Anesthetics, Local; Humans; Pain, Postoperative; Randomized Controlled Trials as Topic; Surgical Procedures, Operative
PubMed: 24244968
DOI: 10.1002/bjs.9204 -
Journal of Gastroenterology Aug 2022This meta-analysis aimed to compare the incidence of gallstone formation, subsequent biliary disease and the need for cholecystectomy in untreated patients and patients... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This meta-analysis aimed to compare the incidence of gallstone formation, subsequent biliary disease and the need for cholecystectomy in untreated patients and patients treated with ursodeoxycholic acid (UDCA) following bariatric surgery.
METHODS
Randomized controlled trials (RCTs) comparing UDCA and controls for the prevention of gallstone formation after bariatric surgery published until February 2022 were selected and subjected to a systematic review and meta-analysis. Articles were searched in the MEDLINE, Web of Science and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0.
RESULTS
Eleven randomized controlled studies were included, with a total of 2363 randomized patients and 2217 patients analysed in the UDCA group versus 1415 randomized patients and 1257 patients analysed in the control group. Considering analysed patients, prophylactic use of UDCA was significantly associated with decreased (i) gallstone formation (OR = 0.25, 95% CI = 0.21-0.31), (ii) symptomatic gallstone disease (GD) (OR = 0.29, 95% CI = 0.20-0.42) and consequently (iii) cholecystectomy rate (OR = 0.33, 95% CI = 0.20-0.55). The results were similar in ITT analysis, in the subgroup of patients undergoing sleeve gastrectomy or considering only randomized versus placebo studies.
CONCLUSIONS
Prophylactic use of UDCA after bariatric surgery prevents both gallstone formation and symptomatic GD and reduces the need for cholecystectomy.
Topics: Bariatric Surgery; Cholecystectomy; Gallstones; Humans; Obesity, Morbid; Randomized Controlled Trials as Topic; Ursodeoxycholic Acid
PubMed: 35704084
DOI: 10.1007/s00535-022-01886-4 -
Anesthesia and Analgesia May 2015Obstructive sleep apnea (OSA) is a commonly encountered comorbid condition in patients undergoing surgery and is associated with a greater risk of postoperative adverse... (Meta-Analysis)
Meta-Analysis Review
The Effects of Continuous Positive Airway Pressure on Postoperative Outcomes in Obstructive Sleep Apnea Patients Undergoing Surgery: A Systematic Review and Meta-analysis.
BACKGROUND
Obstructive sleep apnea (OSA) is a commonly encountered comorbid condition in patients undergoing surgery and is associated with a greater risk of postoperative adverse events. Our objective in this review was to investigate the effectiveness of continuous positive airway pressure (CPAP) in reducing the risk of postoperative adverse events in patients with OSA undergoing surgery, the perioperative Apnea-Hypopnea Index (AHI), and the hospital length of stay (LOS).
METHODS
We performed a systematic search of the literature databases. We reviewed the studies that included the following: (1) adult surgical patients (>18 years old) with information available on OSA; (2) patients using either preoperative and/or postoperative CPAP or no-CPAP; (3) available reports on postoperative adverse events, preoperative and postoperative AHI, and LOS; and (4) all published studies in English including case series.
RESULTS
Six studies that included 904 patients were eligible for the meta-analysis. The meta-analysis for postoperative adverse events was performed in 904 patients (CPAP: n = 471 vs no-CPAP: n = 433; adverse events: 134 vs 133; P = 0.19). There was no significant difference in the postoperative adverse events between the 2 groups. The preoperative baseline AHI without CPAP was reduced significantly with postoperative use of CPAP (preoperative AHI versus postoperative AHI, 37 ± 19 vs 12 ± 16 events per hour, P < 0.001). LOS showed a trend toward significance in the CPAP group versus the no-CPAP group (4.0 ± 4 vs 4.4 ± 8 days, P = 0.05).
CONCLUSIONS
Our review suggests that there was no significant difference in the postoperative adverse events between CPAP and no-CPAP treatment. Patients using CPAP had significantly lower postoperative AHI and a trend toward shorter LOS. There may be potential benefits in the use of CPAP during the perioperative period.
Topics: Chi-Square Distribution; Comorbidity; Continuous Positive Airway Pressure; Humans; Length of Stay; Odds Ratio; Postoperative Complications; Risk Factors; Sleep Apnea, Obstructive; Surgical Procedures, Operative; Time Factors
PubMed: 25899270
DOI: 10.1213/ANE.0000000000000634 -
International Journal of Gynecological... Feb 2021Venous thromboembolism remains a significant complication following major gynecologic surgery. Evidence is lacking on whether it is beneficial to give pharmacologic... (Meta-Analysis)
Meta-Analysis
Efficacy of pre-operative pharmacologic thromboprophylaxis on incidence of venous thromboembolism following major gynecologic and gynecologic oncology surgery: a systematic review and meta-analysis.
INTRODUCTION
Venous thromboembolism remains a significant complication following major gynecologic surgery. Evidence is lacking on whether it is beneficial to give pharmacologic thromboprophylaxis pre-operatively. The aim of this meta-analysis was to assess the role of pre-operative pharmacologic thromboprophylaxis in preventing post-operative venous thromboembolism.
METHODS
PubMed, EMBASE, and the Cochrane Central Register of Clinical Trials were searched to find randomized controlled, cohort, and case-control trials comparing pre-operative pharmacologic thromboprophylaxis to no prophylaxis, mechanical prophylaxis, or only post-operative pharmacologic thromboprophylaxis for open and minimally invasive major gynecologic surgery (benign and malignant conditions). Two authors independently assessed abstracts, full-text articles, and methodological quality. Data were extracted and pooled using ORs for random effects meta-analysis. Heterogeneity was explored using forest plots, Q-statistic, and I statistics. Planned subgroup analysis of use of sequential compression devices, equivalent versus non-equivalent post-operative prophylaxis, cancer diagnosis, and methodological quality were performed.
RESULTS
Some 503 unique studies were found, and 16 studies (28 806 patients) were included in the systematic review. Twelve studies (14 273 patients) were included in the meta-analysis. The OR for incidence of post-operative venous thromboembolism was 0.59 (95% CI 0.39, 0.89), favoring pre-operative pharmacologic thromboembolism prophylaxis compared with no pre-operative pharmacologic prophylaxis (Q=13.80, I=20.30). In studies where post-operative care was equivalent between groups, the OR for venous thromboembolism was 0.56 (95% CI 0.22, 1.40). Pre-operative pharmacologic prophylaxis demonstrated greatest benefit when utilized with both intra-operative and post-operative sequential compression devices (OR 0.43, 95% CI 0.30, 0.64) compared with when no sequential compression devices were utilized (OR 1.27, 95% CI 0.63, 2.56). When looking at only studies determined to be of high quality, the results no longer reached significance (OR 0.73, 95% CI 0.36, 1.46).
CONCLUSIONS
Pre-operative pharmacologic thromboprophylaxis decreases the odds of venous thromboembolism in the peri-operative period for major gynecologic oncology surgery by approximately 40%. It remains unclear whether this benefit is present in benign and minor procedures. Adequately powered studies are needed.
Topics: Anticoagulants; Chemoprevention; Female; Gynecologic Surgical Procedures; Humans; Postoperative Complications; Venous Thromboembolism
PubMed: 33214216
DOI: 10.1136/ijgc-2020-001991 -
Journal of Cranio-maxillo-facial... Jan 2017To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) investigating the efficacy and safety of topical tranexamic acid (TXA) to prevent... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) investigating the efficacy and safety of topical tranexamic acid (TXA) to prevent postoperative bleeding in anticoagulated patients undergoing minor oral surgery.
MATERIAL AND METHODS
We analyzed RCTs comparing the use of topical TXA versus other topical hemostatic agents or placebo solutions for minor oral surgeries. We assessed the risk of bias and strength of evidence according to the Cochrane guidelines and GRADE rating system, respectively. The pooled relative risk (RR) was calculated for the effect of topical application of TXA on postsurgical bleeding.
RESULTS
Five RCTs were included in the study. The combined RR for the number of patients receiving TXA in comparison to the control group was 0.13 (95% CI 0.05-0.36; P = 0.01), indicating a protective effect of topical TXA on bleeding after minor oral surgeries. Subgroup analysis revealed that topical TXA was effective in preventing postsurgical bleeding compared to placebo and epsilon-aminocaproic acid. No cases of thromboembolic events were reported.
CONCLUSIONS
Currently available evidence suggests that surgical site irrigation with TXA followed by mouthwash during the first postoperative week is safe and may reduce the risk of bleeding after minor oral surgeries in anticoagulated patients.
Topics: Administration, Topical; Anticoagulants; Antifibrinolytic Agents; Humans; Oral Surgical Procedures; Postoperative Hemorrhage; Tranexamic Acid
PubMed: 27840121
DOI: 10.1016/j.jcms.2016.10.001