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The Cochrane Database of Systematic... May 2015Uncontrolled bleeding is an important cause of death in trauma victims. Antifibrinolytic treatment has been shown to reduce blood loss following surgery and may also be... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Uncontrolled bleeding is an important cause of death in trauma victims. Antifibrinolytic treatment has been shown to reduce blood loss following surgery and may also be effective in reducing blood loss following trauma.
OBJECTIVES
To assess the effect of antifibrinolytic drugs in patients with acute traumatic injury.
SEARCH METHODS
We ran the most recent search in January 2015. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (OvidSP), PubMed and clinical trials registries.
SELECTION CRITERIA
Randomised controlled trials of antifibrinolytic agents (aprotinin, tranexamic acid [TXA], epsilon-aminocaproic acid and aminomethylbenzoic acid) following acute traumatic injury.
DATA COLLECTION AND ANALYSIS
From the results of the screened electronic searches, bibliographic searches, and contacts with experts, two authors independently selected trials meeting the inclusion criteria, and extracted data. One review author assessed the risk of bias for key domains.Outcome measures included: mortality at end of follow-up (all-cause); adverse events (specifically vascular occlusive events [myocardial infarction, stroke, deep vein thrombosis or pulmonary embolism] and renal failure); number of patients undergoing surgical intervention or receiving blood transfusion; volume of blood transfused; volume of intracranial bleeding; brain ischaemic lesions; death or disability.We rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach.
MAIN RESULTS
Three trials met the inclusion criteria.Two trials (n = 20,451) assessed the effect of TXA. The larger of these (CRASH-2, n = 20,211) was conducted in 40 countries and included patients with a variety of types of trauma; the other (n = 240) restricted itself to those with traumatic brain injury (TBI) only.One trial (n = 77) assessed aprotinin in participants with major bony trauma and shock.The pooled data show that antifibrinolytic drugs reduce the risk of death from any cause by 10% (RR 0.90, 95% CI 0.85 to 0.96; P = 0.002) (quality of evidence: high). This estimate is based primarily on data from the CRASH-2 trial of TXA, which contributed 99% of the data.There is no evidence that antifibrinolytics have an effect on the risk of vascular occlusive events (quality of evidence: moderate), need for surgical intervention or receipt of blood transfusion (quality of evidence: high). There is no evidence for a difference in the effect by type of antifibrinolytic (TXA versus aprotinin) however, as the pooled analyses were based predominantly on trial data concerning the effects of TXA, the results can only be confidently applied to the effects of TXA. The effects of aprotinin in this patient group remain uncertain.There is some evidence from pooling data from one study (n = 240) and a subset of data from CRASH-2 (n = 270) in patients with TBI which suggest that TXA may reduce mortality although the estimates are imprecise, the quality of evidence is low, and uncertainty remains. Stronger evidence exists for the possibility of TXA reducing intracranial bleeding in this population.
AUTHORS' CONCLUSIONS
TXA safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events. TXA should be given as early as possible and within three hours of injury, as further analysis of the CRASH-2 trial showed that treatment later than this is unlikely to be effective and may be harmful. Although there is some promising evidence for the effect of TXA in patients with TBI, substantial uncertainty remains.Two ongoing trials being conducted in patients with isolated TBI should resolve these remaining uncertainties.
Topics: Aminocaproic Acid; Antifibrinolytic Agents; Aprotinin; Blood Loss, Surgical; Blood Transfusion; Hemorrhage; Humans; Randomized Controlled Trials as Topic; Tranexamic Acid; Wounds and Injuries
PubMed: 25956410
DOI: 10.1002/14651858.CD004896.pub4 -
European Urology Aug 2016Overall, 4-10% of patients with renal cell carcinoma (RCC) present with venous tumour thrombus. It is uncertain which surgical technique is best for these patients.... (Review)
Review
CONTEXT
Overall, 4-10% of patients with renal cell carcinoma (RCC) present with venous tumour thrombus. It is uncertain which surgical technique is best for these patients. Appraisal of outcomes with differing techniques would guide practice.
OBJECTIVE
To systematically review relevant literature comparing the outcomes of different surgical therapies and approaches in treating vena caval thrombus (VCT) from nonmetastatic RCC.
EVIDENCE ACQUISITION
Relevant databases (Medline, Embase, and the Cochrane Library) were searched to identify relevant comparative studies. Risk of bias and confounding assessments were performed. A narrative synthesis of the evidence was presented.
EVIDENCE SYNTHESIS
The literature search identified 824 articles. Fourteen studies reporting on 2262 patients were included. No distinct surgical method was superior for the excision of VCT, although the method appeared to be dependent on tumour thrombus level. Minimal access techniques appeared to have better perioperative and recovery outcomes than traditional median sternotomy, but the impact on oncologic outcomes is unknown. Preoperative renal artery embolisation did not offer any oncologic benefits and instead resulted in significantly worse perioperative and recovery outcomes, including possibly higher perioperative mortality. The comparison of cardiopulmonary bypass versus no cardiopulmonary bypass showed no differences in oncologic outcomes. Overall, there were high risks of bias and confounding.
CONCLUSIONS
The evidence base, although derived from retrospective case series and complemented by expert opinion, suggests that patients with nonmetastatic RCC and VCT and acceptable performance status should be considered for surgical intervention. Despite a robust review, the findings were associated with uncertainty due to the poor quality of primary studies available. The most efficacious surgical technique remains unclear.
PATIENT SUMMARY
We examined the literature on the benefits of surgery to remove kidney cancers that have spread to neighbouring veins. The results suggest such surgery, although challenging and associated with high risk of complications, appears to be feasible and effective and should be contemplated for suitable patients if possible; however, many uncertainties remain due to the poor quality of the data.
Topics: Carcinoma, Renal Cell; Humans; Kidney Neoplasms; Neoplasm Staging; Risk Adjustment; Surgical Procedures, Operative; Vascular Neoplasms; Venae Cavae
PubMed: 26707869
DOI: 10.1016/j.eururo.2015.11.034 -
The Cochrane Database of Systematic... Mar 2011Veno-venous bypass is used to overcome the effects of clamping of the inferior vena cava and portal vein during liver transplanation. The routine use of veno-venous... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Veno-venous bypass is used to overcome the effects of clamping of the inferior vena cava and portal vein during liver transplanation. The routine use of veno-venous bypass is, however, controversial.
OBJECTIVES
To compare the benefits and harms of veno-venous bypass (irrespective of open or percutaneous technique; heparin-coated or no heparin-coating) versus no veno-venous bypass during liver transplantation. To compare the benefits and harms of the different techniques of veno-venous bypass during liver transplantation.
SEARCH STRATEGY
We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until December 2010.
SELECTION CRITERIA
We included randomised clinical trials comparing veno-venous bypass during liver transplantation (irrespective of language or publication status).
DATA COLLECTION AND ANALYSIS
Two authors independently assessed trials for inclusion and independently extracted data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For continuous outcomes, we calculated the mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat or available case analysis. For binary outcomes, we used the Fisher's exact test since none of the comparisons of binary outcomes included more than one trial.
MAIN RESULTS
We identified three trials with high risk of bias which compared veno-venous bypass (n = 65) versus no veno-venous bypass (n = 66). None of the trials reported patient or graft survival. There were no significant differences regarding renal failure or blood transfusion requirements between the two groups. None of the trials reported on the morbidity related to veno-venous bypass or the requirement of veno-venous bypass in the control group.We identified one trial with high risk of bias which compared percutaneous (n = 20) versus open technique (n =19) of veno-venous bypass. The patient or graft survival was not reported. There was no difference in veno-venous bypass related morbidity between the two groups. The operating time was significantly shorter in the percutaneous technique group (MD -59 minutes; 95% CI -102 to -16).
AUTHORS' CONCLUSIONS
There is no evidence to support or refute the use of veno-venous bypass in liver transplantation. There is no evidence to prefer any particular technique of veno-venous bypass in liver transplantation.
Topics: Blood Transfusion; Extracorporeal Circulation; Humans; Liver; Liver Transplantation; Portal Vein; Randomized Controlled Trials as Topic; Renal Insufficiency; Vena Cava, Inferior; Vena Cava, Superior
PubMed: 21412907
DOI: 10.1002/14651858.CD007712.pub2 -
Journal of Evidence-based Medicine Nov 2013The aim of this study was to systematically review the effects of transfusing Tol-DCs induced by different methods on renal transplantation and survival time. (Review)
Review
OBJECTIVE
The aim of this study was to systematically review the effects of transfusing Tol-DCs induced by different methods on renal transplantation and survival time.
METHOD
PubMed and EMbase were searched for relevant articles from inception to July 20(th), 2013. Renal allograft survival time was regarded as the endpoint outcome. The effects of Tol-DCs on renal transplantation were evaluated semi-quantitatively.
RESULTS
Sixteen articles were included. There were three sources of Tol-DCs, including bone marrow, spleen, and thoracic duct lymph node. Rats were administrated cells intravenously and 83% of mice through the portal vein. Four subtypes of bone marrow Tol-DCs enhanced renal allograft time: immature DCs enhanced allograft survival 4.9-fold in rats and 2.0-fold in mice, gene modified DCs enhanced allograft survival 4.4-fold in rats and 2.2-fold in mice, and drug and cytokine induced enhanced allograft survival 2.9-fold and 2.7-fold, respectively, in rats. Tol-DCs from the spleen and thoracic duct lymph nodes prolonged allograft survival 2.7-fold and 1.8-fold, respectively, in rats. 1-2 × 10(6) doses of Tol-DCs extended the survival time of rats following renal transplantation. The key mechanisms by which Tol-DCs enhance allograft and overall survival included: (i) inducing T-cell hyporeactivity; (ii) reducing the effects of cytotoxic lymphocytes; and (iii) inducing Th2 differentiation.
CONCLUSION
Bone marrow Tol-DCs can extend allograft survival and induce immune tolerance in fully MHC-mismatched renal transplantation in rats and mice. The effects of imDCs and gene modified Tol-DCs in mice are less marked. In conclusion, a single-injection of 1-2 × 10(6) doses of bone marrow Tol-DCs (i.v.), in combination with an immune-suppressor, a co-stimulator, and accessory cells can significantly extend renal allograft survival.
Topics: Adoptive Transfer; Allografts; Animals; Dendritic Cells; Evidence-Based Medicine; Graft Survival; Humans; Immune Tolerance; Kidney Transplantation; Mice; Rats
PubMed: 24325419
DOI: 10.1111/jebm.12070 -
Transplantation Reviews (Orlando, Fla.) Apr 2017Small-for-size syndrome (SFSS) has an incidence between 0 and 43% in small-for-size graft (SFSG) adult living donor liver transplantation (LDLT). Portal hypertension... (Review)
Review
INTRODUCTION
Small-for-size syndrome (SFSS) has an incidence between 0 and 43% in small-for-size graft (SFSG) adult living donor liver transplantation (LDLT). Portal hypertension following reperfusion and the hyperdynamic splanchnic state are reported as the major triggering factors of SFSS. Intra- and postoperative strategies to prevent or to reduce its onset are still under debate. We analyzed graft inflow modulation (GIM) during adult LDLT considering the indications, efficacy of the available techniques, changes in hemodynamics and outcomes.
MATERIALS AND METHODS
A systematic literature search was performed using PubMed, EMBASE, Scopus and the Cochrane Library Central. Treatment outcomes including in-hospital mortality and morbidity, re-transplantation rate, 1-, 3-, and 5-year patient overall survival and 1-, 3-, and 5-year graft survival rates, hepatic artery and portal vein flows and pressures before and after inflow modulation were analyzed.
RESULTS
From 563 articles, 12 studies dated between 2003 and 2014 fulfilled the selection criteria and were therefore included in the study. These comprised a total of 449 adult patients who underwent inflow modulation during adult-to-adult LDLT. Types of GIM described were splenic artery ligation, splenectomy, meso-caval shunt, spleno-renal shunt, portocaval shunt, and splenic artery embolization. Mortality and morbidity ranged between 0 and 33% and 17% and 70%, respectively. Re-transplantation rates ranged between 0% and 25%. GIM was associated with good survival for both graft and recipients, reaching an 84% actuarial rate at 5 years. Through the use of GIM, irrespective of the technique, a statistically significant reduction of PVF and PVP was obtained.
CONCLUSIONS
GIM is a safe and efficient technique to avoid or limit portal hyperperfusion, especially in cases of SFSG, decreasing overall morbidity and improving outcomes.
Topics: Adult; Female; Graft Rejection; Graft Survival; Humans; Liver Circulation; Liver Transplantation; Living Donors; Male; Portacaval Shunt, Surgical; Prognosis; Risk Assessment; Survival Rate; Treatment Outcome
PubMed: 27989547
DOI: 10.1016/j.trre.2016.11.002 -
JPMA. the Journal of the Pakistan... Feb 2024To identify and critically appraise literature on true brachial artery aneurysm, exploring its demographic characteristics, aetiologies, clinical manifestations and...
OBJECTIVE
To identify and critically appraise literature on true brachial artery aneurysm, exploring its demographic characteristics, aetiologies, clinical manifestations and different methods of repair along with complication rates to determine future treatment strategies.
METHODS
The systematic review was conducted at Liaquat National Hospital, Karachi, from September 30, 2021, to November 30, 2022, in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Literature was searched on MEDLINE, EMBASE and Cochrane databases for relevant studies in English language or with English translation published till May 31, 2022. The key words used for the search were "brachial artery aneurysm". Data was noted on a proforma and was subjected to descriptive analysis.
RESULTS
Of 113 articles, 6 (5.3%) were retrospective studies, 7 (6.1%) were case series and 100 (88.4%) were case reports. The total number of patients involved was 157 with mean age 43.1±23.4 years (range: 2 months to 84 years). The gender was mentioned for 152(96.8%) patients; 111(73%) males and 41(27%) females. The mean diameter of true brachial artery aneurysm was 36.2 ±17.5mm and 106(67.5%) patients presented with localised swelling, 65(41.4%) with pain, 41(26.1%) with distal ischaemic symptoms, and 28(17.8%) with median nerve compression. True brachial artery aneurysms were more common in renal failure patients having a history of arteriovenous fistula creation in the affected limb and were on immunosuppressant drugs due to renal transplant 81(51.5%). Less common causes included primary/idiopathic 27(17.1%), trauma 13(8.2%), connective tissue disorders 8(5%) and vasculitis 7(4.5%). The treatment of choice was aneurysmectomy in 142(90.4%) cases, with revascularisation of limb primarily with reversed great saphenous vein graft 79(50.3 %), followed by end-to-end anastomosis of brachial artery 17(10.8%) and synthetic grafting 17(10.8%). Endovascular intervention was performed in 6(3.8%) cases to exclude true brachial artery aneurysm, and to re-establish adequate blood flow to the associated limb.
CONCLUSION
True brachial artery aneurysm, although a rarity, may lead to significant neurological and vascular problems if ignored. Arteriovenous fistula and immunosuppression are identified as two significant risk factors in the development of true brachial artery aneurysm. Therefore, an effective long-term follow up in renal failure patients is recommended to prevent its complications. Open surgical repair has been the most preferred mode of treatment, but further significant studies are needed to explore and compare different modes of surgical intervention, like open versus endovascular, to plan future treatment strategies.
Topics: Male; Female; Humans; Young Adult; Adult; Middle Aged; Aged; Brachial Artery; Retrospective Studies; Treatment Outcome; Aneurysm; Arteriovenous Fistula; Renal Insufficiency
PubMed: 38419237
DOI: 10.47391/JPMA.9042 -
European Journal of Vascular and... Oct 2009Aneurysms of the visceral veins are considered rare clinical entities. The aim is to assess their clinical presentation, natural history and management. (Review)
Review
AIM
Aneurysms of the visceral veins are considered rare clinical entities. The aim is to assess their clinical presentation, natural history and management.
METHODS
An electronic search of the pertinent English and French literature was undertaken. All studies reporting on aneurysms of visceral veins were considered. Cases describing patients with arterial-venous fistulae and extrahepatic or intra-hepatic portosystemic venous shunts were excluded.
RESULTS
Ninety-three reports were identified, including 176 patients with 198 visceral venous aneurysms. Patients' age ranges from 0 to 87 years, and there is no apparent male/female preponderance. The commonest location of visceral venous aneurysms is the portal venous system (87 of 93 reports, 170 of 176 patients, 191 of 198 aneurysms). Aneurysms of the renal veins and inferior mesenteric vein are also described. Portal system venous aneurysms were present with abdominal pain in 44.7% of the patients, gastrointestinal bleeding in 7.3%, and are asymptomatic in 38.2%. Portal hypertension is reported in 30.8% and liver cirrhosis in 28.3%. Thrombosis occurred in 13.6% and rupture in 2.2% of the patients. Adjacent organ compression is reported in 2.2% (organs compressed: common bile duct, duodenum, inferior vena cava). The management ranged from watchful waiting to intervention. In 94% of the cases, aneurysm diameter remained stable and no complications occurred during follow-up. In most of the cases, indications for operation were symptoms and complications. Six cases of renal vein aneurysm are reported; three of them were asymptomatic. Three of these patients were treated surgically.
CONCLUSION
The most frequent location of visceral venous aneurysms is the portal venous system. They are often associated with cirrhosis and portal hypertension. They may be asymptomatic or present with abdominal pain and other symptoms. Watchful waiting is an appropriate treatment, except when complications occur. Most common complications are aneurysm thrombosis and rupture. Other visceral venous aneurysms are extremely rare.
Topics: Abdominal Pain; Adolescent; Adult; Aged; Aged, 80 and over; Aneurysm; Aneurysm, Ruptured; Child; Child, Preschool; Disease Progression; Female; Humans; Infant; Infant, Newborn; Male; Mesenteric Veins; Middle Aged; Portal Vein; Renal Veins; Severity of Illness Index; Thrombosis; Treatment Outcome; Vascular Surgical Procedures; Viscera; Young Adult
PubMed: 19560947
DOI: 10.1016/j.ejvs.2009.05.016 -
Journal of Personalized Medicine Aug 2023The use of robotic surgery is attracting ever-growing interest for its potential advantages such as small incisions, fine movements, and magnification of the operating...
BACKGROUND
The use of robotic surgery is attracting ever-growing interest for its potential advantages such as small incisions, fine movements, and magnification of the operating field. Only a few randomized controlled trials (RCTs) have explored the differences in perioperative outcomes between the two approaches.
METHODS
We screened the main online databases from inception to May 2023. We included studies in English enrolling adult patients undergoing elective gastrointestinal surgery. We used the following exclusion criteria: surgery with the involvement of thoracic esophagus, and patients affected by severe heart, pulmonary and end-stage renal disease. We compared intra- and post-operative complications, length of hospitalization, and costs between laparoscopic and robotic approaches.
RESULTS
A total of 18 RCTs were included. We found no differences in the rate of anastomotic leakage, cardiovascular complications, estimated blood loss, readmission, deep vein thrombosis, length of hospitalization, mortality, and post-operative pain between robotic and laparoscopic surgery; post-operative pneumonia was less frequent in the robotic approach. The conversion to open surgery was less frequent in the robotic approach, which was characterized by shorter time to first flatus but higher operative time and costs.
CONCLUSIONS
The robotic gastrointestinal surgery has some advantages compared to the laparoscopic technique such as lower conversion rate, faster recovery of bowel movement, but it has higher economic costs.
PubMed: 37763064
DOI: 10.3390/jpm13091297 -
Journal of Investigative Surgery : the... Mar 2021: The increasing prevalence of chronic kidney disease (CKD) in recent years and its impact on renal dysfunction on orthopedic surgery continues to draw more attention to... (Meta-Analysis)
Meta-Analysis
: The increasing prevalence of chronic kidney disease (CKD) in recent years and its impact on renal dysfunction on orthopedic surgery continues to draw more attention to orthopedic surgeons. The purpose of this study is to investigate the influence of CKD on comorbidities and complications in patients who underwent elective low limbs surgery. : Until August 2018, Pubmed, Embase, Cochrane library, and Web of science were used to search relevant literature. After reviewing the article title, the abstract, and the full text, a total of 11 articles were identified in the qualitative synthesis. Demographic data, comorbidities, and complications were assessed between CKD and non-CKD patients. Review Manager 5.3 was used for the statistical analysis, and forest plots were constructed for each variable. : A total of 137,436 patients (10,732 patients with CKD and 126,704 patients without CKD) from 11 studies were enrolled in this meta-analysis. CKD patients showed worse health conditions in comparison to non-CKD patients. The incidence of several preoperative comorbidities (hypertension, diabetes, and cardiac-cerebral disease) and postoperative complications (infection, transfusion, deep vein thrombosis, and early mortality) were higher in CKD patients. : In elective hip and knee surgery, compared with non-CKD patients, CKD patients showed worse health conditions. Due to a higher rate of comorbidities and complications in CKD patients, they should be treated carefully during perioperative periods.
Topics: Elective Surgical Procedures; Humans; Orthopedic Procedures; Postoperative Complications; Renal Insufficiency, Chronic; Retrospective Studies
PubMed: 31500490
DOI: 10.1080/08941939.2019.1631412 -
Clinical Endocrinology Jul 2023Complete resolution of hypertension (CRH) after adrenalectomy for primary aldosteronism is far from a certainty. Although several prognostic models have been proposed to... (Meta-Analysis)
Meta-Analysis Review
Complete resolution of hypertension (CRH) after adrenalectomy for primary aldosteronism is far from a certainty. Although several prognostic models have been proposed to predict outcome after adrenalectomy, studies have not clarified which of the available models can be used reliably in clinical practice. To identify, describe and appraise all prognostic models developed to predict CRH, and meta-analyse their predictive performances. We searched MEDLINE, Embase and Web of Science for development and validation studies of prognostic models. After selection, we extracted descriptive statistics and aggregated area under the receiver operator curve (AUC) using meta-analysis. From 25 eligible studies, we identified 12 prognostic models used for predicting CRH after total adrenalectomy in primary aldosteronism. We report the results for 3 models that had available data from at least 3 external validation studies: the primary aldosteronism surgical outcome (PASO) score (AUC: 0.81; 95% confidence interval [CI]: 0.74-0.86; 95% predictive interval [PI]: 0.04-1.00), Utsumi nomogram (AUC: 0.79; 95% CI: 0.72-0.85; 95% PI: 0.03-1.00) and the aldosteronoma resolution score (ARS) model (AUC: 0.77; 95% CI: 0.74-0.80; 95% PI: 0.59-0.86 for all studies and AUC: 0.80; 95% CI: 0.75-0.85; 95% PI: 0.57-0.93 for the studies with the same adrenal vein sampling-guided adrenalectomy rate compared to the models meta-analysed). The PASO score, Utsumi nomogram and ARS model showed comparable discrimination performance to predict CRH in primary aldosteronism. Unlike the ARS model, the number of external validation studies for the PASO score and the Utsumi nomogram was relatively low to draw definite conclusions.
Topics: Humans; Prognosis; Adrenalectomy; Hypertension; Adrenocortical Adenoma; Hyperaldosteronism; Retrospective Studies; Aldosterone
PubMed: 37032125
DOI: 10.1111/cen.14918