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1.
Prostate Artery Embolization in the Treatment of Massive Intractable Bleeding from Prostatic Neoplasms: A Case Report and Systematic Review
Moramarco, L., Grande, A. M., Vertemati, M., Aseni, P.
Journal of clinical medicine. 2023;13(1)
Abstract
Lower urinary tract symptoms (LUTS) and hematuria are common symptoms in men with neoplasms, mainly affecting the elderly population. Prostatic arterial embolization (PAE) is a minimally invasive procedure that has shown promising results in managing LUTS and massive intractable prostatic hematuria in patients with benign prostatic hyperplasia (BPH) and prostate cancer (PCa). A few studies, however, have provided valuable insights into the durability and efficacy of PAE focusing on the long-term effectiveness, quality of life, and cancer-specific control of hemostasis and urinary symptoms. As a result of concomitant cardiovascular conditions, these patients often take anticoagulants or antithrombotics, which can worsen their hematuria and clinical status. Transurethral resection of the prostate (TURP) is considered a very high-risk procedure, even without massive bleeding, and requires discontinuation of vitamin K antagonists and antiplatelet therapies. Such patients usually have their surgery postponed, and PAE should be considered a safe alternative treatment. We aimed to report a narrative review from 1976 to June 2023 of the current state of PAE for massive and intractable hematuria, highlighting recent developments in this technique, including prospective cohort studies, and focusing on long-term outcome, safety, and complication management of patients with prostatic neoplasms who develop significant hemorrhagic symptoms. Additionally, we present a case report and a simple algorithm for treating intractable bleeding in a 92-year-old man with PCa and massive hematuria.
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2.
Efficacy and safety of gastroscopic hemostasis in the treatment of acute gastric hemorrhage: A meta-analysis
Pan, H. Y., Wang, X. W., He, Q. X., Lu, Y. D., Zhang, W. Y., Jin, J. W., Lin, B.
World journal of gastrointestinal oncology. 2023;15(11):1988-1997
Abstract
BACKGROUND Gastric cancer (GC) is a malignant tumor with a high incidence and mortality rate worldwide for which acute bleeding is a common clinical complication. Gastroscopic hemostasis is an important method for treating acute bleeding in GC; however, its efficacy and safety remain controversial. AIM: To systematically analyze the efficacy and safety of gastroscopic hemostasis for the treatment of acute gastric hemorrhage. METHODS The PUBMED, Web of Science, Wiley Library, EMBASE, Wanfang, CNKI, and VIP databases were searched for studies related to gastroscopic hemostatic treatment for acute GC published through February 20, 2023. The literature was screened according to the inclusion and exclusion criteria, data were extracted, and literature quality was evaluated. The meta-analysis was performed using RevMan software (version 5.3), while Begg's test for publication bias was performed using Stata 13.0 software. RESULTS Six randomized controlled trials and two retrospective analyses were retrieved. Five studies had a low, two had an uncertain, and one had a high risk of bias. Compared with the control group, the hemostatic rate of gastroscopic hemostasis was increased [relative risk (RR) = 1.24; 95% confidence interval (CI): 1.08 to 1.43; P = 0.003]; the rate of rebleeding (RR = 0.27; 95%CI: 0.09 to 0.80; P = 0.02), rate of surgery transfer (RR = 0.16; 95%CI: 0.06 to 0.43; P = 0.0003), serum C-reactive protein level [mean difference (MD) = -5.16; 95%CI: -6.11 to 4.21; P < 0.00001], interleukin-6 level (MD = -6.37; 95%CI: -10.33 to -2.42; P = 0.002), and tumor necrosis factor-α level (MD = -2.29; 95%CI: -4.06 to -0.52; P = 0.01) were decreased; and the quality of life improvement rate was increased (RR = 1.95; 95%C I= 1.41-2.71; P < 0.0001). Begg's test revealed no significant publication bias. CONCLUSION The efficacy and safety of endoscopic hemostasis were higher than those of the control group, suggesting that it is an effective treatment for acute GC hemorrhage.
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3.
Prophylactic clipping to prevent delayed colonic post-polypectomy bleeding: meta-analysis of randomized and observational studies
Bishay K, Meng, ZW, Frehlich L., James MT, Kaplan GG, Bourke MJ, Hilsden RJ, Heitman SJ, Forbes N
Surgical endoscopy. 2021
Abstract
BACKGROUND AND AIMS Delayed post-polypectomy bleeding (DPPB) is a commonly described adverse event following polypectomy. Prophylactic clipping may prevent DPPB in some patient subgroups. We performed a meta-analysis to assess both the efficacy and real-world effectiveness of prophylactic clipping. METHODS We performed a database search through March 2020 for clinical trials or observational studies assessing prophylactic clipping and DPPB. Pooled risk ratios (RR) were calculated using random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to elucidate clinical or methodological factors associated with effects on outcomes. RESULTS A total of 2771 citations were screened, with 11 randomized controlled trials (RCTs) and 9 observational studies included, representing 24,670 colonoscopies. DPPB occurred in 2.0% of patients overall. The pooled RR of DPPB was 0.47 (95% CI 0.29-0.77) from RCTs enrolling only patients with polyps ≥ 20 mm. Remaining pooled RCT data did not demonstrate a benefit for clipping. The pooled RR of DPPB was 0.96 (95% CI 0.61-1.51) from observational studies including all polyp sizes. For patients with proximal polyps of any size, the RR was 0.73 (95% CI 0.33-1.62) from RCTs. Meta-regression confirmed that polyp size ≥ 20 mm significantly influenced the effect of clipping on DPPB. CONCLUSION Pooled evidence demonstrates a benefit when clipping polyps measuring ≥ 20 mm, especially in the proximal colon. In lower-risk subgroups, prophylactic clipping likely results in little to no difference in DPPB.
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4.
Role of prophylactic hemoclip placement in prevention of delayed post-polypectomy bleeding for large colon polyps: a meta-analysis of randomized controlled trials
Gangwani MK, Ahuja P, Aziz A, Rani A, Lee-Smith W, Aziz M
Annals of gastroenterology. 2021;34(3):392-398
Abstract
BACKGROUND Polypectomy is a widely used and effective procedure to treat precancerous polyps. Delayed post-polypectomy bleeding (DPPB), a common complication of polypectomy, may diminish the utility of this procedure. Previous data on the efficacy of hemoclips has been conflicting, therefore we aimed to collectively evaluate and analyze the data to reach a definitive conclusion on the efficacy of using hemoclips to prevent incidences of DPPB in patients with large polyps (≥10 mm). METHODS We identified a total of 261 studies based on our previously defined search strategy. After screening, we included 6 randomized controlled trials. A meta-analysis was performed comparing the use of prophylactic application of hemoclips to a standard group without prophylactic clip placement for large polyps. RESULTS We found a statistically significant reduction in the incidence of DPPB when using hemoclips for large polyps. The overall incidence of DPPB was lower in the hemoclip group compared to the standard group for all large polyps ≥10 mm (relative risk 0.51, 95% confidence interval 0.35-0.75; P=0.01; I (2)=0%). CONCLUSIONS The use of hemoclips in achieving hemostasis for large polyps has a beneficial effect and appears to prevent DPPB. This reinforces the routine clinical practice of using hemoclips in polypectomy procedures.
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5.
Intraoperative balloon occlusion of the aorta for blood management in sacral and pelvic tumor resection: A systematic review and meta-analysis
Bailey AJ, Lee A, Li HO, Glen P
Surgical oncology. 2020;35:156-161
Abstract
BACKGROUND Neoplasms of the sacrum and pelvis are challenging to manage due to their complex vascularity and size and are at high risk of bleeding during resection. Intra-aortic balloon occlusion (IABO) has been used in trauma to control massive blood loss, but its efficacy and safety in oncologic sacral and pelvic surgery are unknown. The primary objective of this systematic review and meta-analysis was to assess the effectiveness of IABO in providing hemorrhage control during resection of sacral and pelvic tumors. METHODS This PROSPERO pre-registered study meta-analyzed all studies reporting on the use of IABO in the setting of pelvic and sacral tumour resection, in accordance with the PRISMA guidelines. The primary outcome of the meta-analysis was intraoperative blood loss, with secondary outcomes consisting of transfusion volume, post-operative blood loss, operative time, complication rate, and mortality. RESULTS Across studies, IABO was associated with a large, significant reduction in intraoperative blood loss (SMD -0.81, 95% CI -1.01 to -0.60, P < 0.0001) and transfused red blood cell volume (SMD 0.92, 95% CI -1.30 to -0.53, P < 0.0001). Two studies reported that complication rates were comparable between patients receiving IABO and patient receiving conventional surgery (Odds ratio = 1.29, 95% CI: 0.59 to 2.83, P = 0.52). All studies descriptively reported improved visualization of the operative field with IABO. CONCLUSIONS Our findings demonstrated that IABO is an effective technique to decrease blood loss and transfusion requirements during sacral and pelvic tumor surgery. Future clinical trials should be conducted to establish the safety of this method and explore potential contraindications.
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6.
The Effects of Hyperbaric Oxygen Therapy on Pelvic Radiation Induced Gastrointestinal Complications (Rectal Bleeding, Diarrhea, and Pain): A Meta-Analysis
Yuan JH, Song LM, Liu Y, Li MW, Lin Q, Wang R, Zhang CS, Dong J
Front Oncol. 2020;10:390
Abstract
Background: Radiotherapy is a routine treatment for pelvic cancer patients. While it had been proven effective, gastrointestinal side effects remain a concern, impairing the quality of life. A few studies focused on the effects of hyperbaric oxygen (HBO) treatment to alleviate radiation-induced gastrointestinal complications. This meta-analysis aimed to critically review and summarize existing literature, assessing the effectiveness of HBO therapy for the treatment of radiation-induced gastrointestinal side effects. Methods: Medical literature search was performed with PubMed, Cochrane Library, and EMBASE up to March 14, 2019. Literatures about HBO treatment upon patients undergoing pelvic cancer (endometrial, cervix, rectum, or prostate cancers) radiotherapy were collected, and the effects of HBO treatment on radiotherapy-induced gastrointestinal complications were evaluated. A random-effects model was used to calculate the pooled effect size. Subgroup analyses were performed to search for sources of heterogeneity. Publication bias was detected with Funnel plots and Egger's test. Results: Three different radiotherapy-related gastrointestinal complications, including rectal bleeding, diarrhea, and pain, were analyzed after screening. It was revealed that the improvement rates were considerable in rectal bleeding (0.81, 95% CI: 0.74-0.89) and diarrhea (0.75, 95% CI: 0.61-0.90) and slightly in pain (0.58, 95% CI: 0.38-0.79). Subgroup analysis revealed factors that significantly influenced the heterogeneity of rectal bleeding, diarrhea, and pain (evaluation criteria, follow-up time, and scoring system, respectively). No significant publication bias was detected. Conclusion: HBO treatment might have the potential to alleviate radiotherapy-related gastrointestinal complications, including rectal bleeding, diarrhea, and pain, but more data are needed for further conclusions. Other symptoms were not further analyzed, as the number of studies was insufficient. More large-scale and prospective studies are needed for better evaluation of HBO's therapeutic values.
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7.
Palliative radiotherapy for gastric cancer: Is there a dose relationship between bleeding response and radiotherapy?
Viani GA, Arruda CV, Hamamura AC, Faustino AC, Danelichen AFB, Matsuura FK, Neves LVF
Clinics (Sao Paulo, Brazil). 2020;75:e1644
Abstract
The aim of this study was to evaluate whether there is a relationship between bleeding response and radiotherapy dose to palliate patients with local recurrence or progression of gastric cancer (GC). To this end, we conducted a systematic review and meta-analysis of observational studies that evaluated the bleeding response in patients with GC with local recurrence or progression. A meta-regression analysis between biological effective dose (BED) and bleeding response was performed, as was subgroup analysis to evaluate the outcome by BED level and radiotherapy (RT) technique. A p-value <0.05 was considered significant. Ten non-comparative retrospective studies and one prospective study were included. In general, RT was effective at controlling tumor bleeding, and the bleeding response rate was 0.77 (95% confidence interval (CI), 0.73-0.81). Meta-regression analysis demonstrated a linear correlation between BED Gy 10 and bleeding response (p=0<0001). Studies using conformational RT had a significant bleeding response rate compared to those using 2D (0.79; 95%CI, 0.74-0.84 vs 0.65; 95%CI, 0.56-0.75; p=0.021). In terms of the BED level, a significant difference in BR was identified on comparing BED Gy10 ≥40 (0.79; 95%CI, 0.7-0.8), BED Gy10 30-39 (0.79, 95%CI, 0.71-0.86), and BED Gy10 <30 (0.64; 95%CI, 0.5-0.7; p=0.0001). The mean survival time was 3.31 months (95%CI, 2.73-3.9) months, and the responders had a significantly longer survival (longer by 2.5 months) compared to the non-responders (95%CI, 1.7-3.3; p<0.0001). Palliative RT is effective at controlling bleeding due to local recurrence/progression from GC. Our findings reveal a relationship between BR and BED. BED <30 Gy 10 should not be recommended, and 3DRT should be indicated instead in order to improve the result.
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8.
Polyglycolic acid sheets decrease post-endoscopic submucosal dissection bleeding in early gastric cancer: a systematic review and meta-analysis
Li DF, Xiong F, Xu ZL, Zhang DG, Yao J, Wang LS
J Dig Dis. 2020
Abstract
Endoscopic submucosal dissection (ESD) is the standard treatment for early gastric cancer (EGC). However, post-ESD bleeding remains a serious issue particularly in patients continued antithrombotic agent treatment or undergone a large mucosal resection (>4 cm). It has been suggested that ulcer bed induced by ESD covered with polyglycolic acid (PGA) sheets can prevent post-ESD bleeding. However, the effectiveness of this procedure has been questioned. To this end, Pubmed, Cochrane library and Embase databases were searched for studies on the effects of PGA sheets shielding on inpatients with EGC and high risk bleeding using post-ESD bleeding rate as the primary outcome. Among the four included studies with 212 lesions in the PGA sheets group and 208 lesions in the control group, post-ESD bleeding rate was significantly lower in the PGA sheet group than in the control group (4.9% vs. 13.7%, risk ratio (RR) 0.33, 95% confidence interval (CI) 0.16-0.69, P = 0.003). Subgroup analysis showed application of PGA sheets effectively reduced the post-ESD bleeding rate in patients receiving antithrombotic agents (5.5% vs. 14.5%, RR 0.39, 95% CI 0.18-0.83, P = 0.01). However, although application of PGA sheets tended to decrease post-ESD bleeding rate in patients who underwent large mucosal resections, the difference was not significantly different (3.0% vs. 9.6%, RR 0.43; 95% CI 0.08-2.23, P = 0.31) and need to be further confirmed.
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9.
Transcatheter arterial embolization for intractable, nontraumatic bladder hemorrhage in cancer patients: a single-center experience and systematic review
Chen C, Kim PH, Shin JH, Yoon KW, Chung MS, Li HL, Hong B
Japanese journal of radiology. 2020
Abstract
PURPOSE To explore the effect of transcatheter arterial embolization (TAE) in controlling intractable, nontraumatic bladder hemorrhage in cancer patients. MATERIALS AND METHODS A literature review (PubMed and EMBASE), followed by a retrospective analysis of all cancer patients with intractable hematuria from bladder treated by TAE at our tertiary referral center. RESULTS At our institution, 27 consecutive cancer patients who underwent TAE for refractory hematuria from bladder were identified. The systematic review included 13 studies published between 1981 and 2019. In our local cohort, 27 patients were treated with 100% technical success, clinical success in 88.9%, no major complications, and rebleeding rate within the first month of 7.4%. In the systematic review cohort of 201 patients, there was technical success in 99.0%, clinical success in 80.9%, major complications in 5.5%, and a rebleeding rate within the first month of 4.5%. Bilateral embolization was performed in 81.1%, and embolization levels were mostly anterior division of internal iliac artery (73.7%) and vesical artery (23.2%). CONCLUSION TAE is effective and safe to control intractable hematuria from bladder origin in cancer patients after failure of conservative management, providing effective temporary hemostasis. For bladder hemorrhage unsuitable for surgery, TAE should be considered at an early stage. A literature review, followed by retrospective analysis of all patients with intractable hematuria from bladder treated by transcatheter arterial embolization at our tertiary referral center. Transcatheter arterial embolization is effective and safe to control intractable hematuria from bladder. The major complication rate and rebleeding within the first month are acceptable.
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10.
Effects of Fibrin Sealant on Seroma Reduction for Patients with Breast Cancer Undergoing Axillary Dissection: Meta-Analysis of Randomized Controlled Trials
Chang YT, Shih SL, Loh EW, Tam KW
Ann Surg Oncol. 2020
Abstract
BACKGROUND Seroma formation is common in patients with breast cancer after axillary dissection. Fibrin sealant, containing fibrinogen and thrombin, has been developed to improve wound healing. We conducted a systematic review and meta-analysis to evaluate the efficacy of fibrin sealants in reducing seroma among patients with breast cancer undergoing axillary dissection. METHODS We searched the PubMed, EMBASE, and Cochrane Library databases for randomized controlled trials (RCTs) published up to April 2020. Pooled estimates of the outcomes were computed using a random-effects model. The primary outcomes were incidence and volume of seroma, while the secondary outcomes were volume and duration of drainage, incidence of infection, and length of hospital stay. RESULTS We reviewed 23 RCTs that included 1640 patients. Compared with the control group, the fibrin sealant group had no significant differences in the incidence of seroma, length of hospital stay, or incidence of surgical site infection. Significant intergroup differences were discovered in lower volume of seroma (weighted mean difference [WMD] - 71.88, 95% confidence interval [CI] - 135.58 to - 8.19), volume of drainage (WMD - 73.24, 95% CI - 107.32 to - 39.15), and duration of drainage (WMD - 0.84, 95% CI - 1.50 to - 0.19). CONCLUSIONS Fibrin sealants provide limited benefits in reducing the volume of seroma and the volume and duration of drainage. Therefore, after shared decision making, surgeons may apply fibrin sealants to patients with breast cancer undergoing axillary dissection.