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1.
Oxidized Regenerated Cellulose Versus Calcium Alginate in Controlling Bleeding From Malignant Wounds: A Randomized Controlled Trial
Firmino F, Villela-Castro D, Santos Vlcg
Cancer nursing. 2023
Abstract
BACKGROUND There is no consensus on the best intervention for topical management of bleeding in malignant wounds. Although surgical hemostatic dressings are recommended, the use of calcium alginate (CA) is frequent among practitioners. OBJECTIVE The aim of this study was to evaluate the hemostatic efficacy of oxidized regenerated cellulose (ORC) and CA dressing in the management of bleeding from malignant wounds resulting from breast cancer. METHODS This was a randomized open clinical trial. The outcomes measured were total time to hemostasis and the number of hemostatic products used. RESULTS Sixty-one patients were potentially eligible for the study, 1 did not consent, and 32 were assessed to be ineligible, resulting in a sample of 28 who were randomized to 2 study groups. Total time to hemostasis was 93.8 seconds in the ORC group, with an average of 30.1 seconds (95% confidence interval, 18.6-189 seconds), and 67 seconds in the CA group, with an average of 30.4 seconds (confidence interval, 21.7 seconds to imprecise upper limit). The main difference was 26.8 seconds. Kaplan-Meier log-rank test, and Cox model showed no statistical significance (P = 0.894). A total of 18 hemostatic products were used in the CA group and 34 in the ORC group. No adverse effects were identified. CONCLUSIONS Although no significant differences were identified in terms of time, more hemostatic products were used in the ORC group, highlighting the effectiveness of CA. IMPLICATIONS FOR PRACTICE Calcium alginate may be the first choice in the management of bleeding in malignant wounds, favoring nursing in the most immediate hemostatic actions.
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2.
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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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.
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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5.
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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6.
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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7.
A Randomized Controlled Trial of Novel Treatment for Hemorrhagic Radiation Proctitis
Pui WC, Chieng TH, Siow SL, Nik Abdullah NA, Sagap I
Asian Pacific journal of cancer prevention : APJCP. 2020;21(10):2927-2934
Abstract
BACKGROUND Various methods have been used for treatment of hemorrhagic radiation proctitis (HRP) with variable results. Currently, the preferred treatment is formalin application or endoscopic therapy with argon plasma coagulation. Recently, a novel therapy with colonic water irrigation and oral antibiotics showed promising results and more effective compared to 4% formalin application for HRP. The study objective is to compare the effect of water irrigation and oral antibiotics versus 4% formalin application in improving per rectal bleeding due to HRP and related symptoms such as diarrhoea, tenesmus, stool frequency, stool urgency and endoscopic findings. METHODS We conducted a study on 34 patients with HRP and randomly assigned the patients to two treatment arm groups (n=17). The formalin group underwent 4% formalin dab and another session 4 weeks later. The irrigation group self-administered daily rectal irrigation at home for 8 weeks and consumed oral metronidazole and ciprofloxacin during the first one week. We measured the patients' symptoms and endoscopic findings before and after total of 8 weeks of treatment in both groups. RESULTS Our study showed that HRP patients had reduced per rectal bleeding (p = 0.003) in formalin group, whereas irrigation group showed reduced diarrhoea (p=0.018) and tenesmus (p=0.024) symptoms. The comparison between the two treatment arms showed that irrigation technique was better than formalin technique for tenesmus (p=0.043) symptom only. CONCLUSION This novel treatment showed benefit in treating HRP. It could be a new treatment option which is safe and conveniently self-administered at home or used as a combination with other therapies to improve the treatment outcome for HRP.
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8.
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.
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9.
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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10.
A novel self-assembling peptide for hemostasis during endoscopic submucosal dissection: a randomized controlled trial
Subramaniam S, Kandiah K, Chedgy F, Fogg C, Thayalasekaran S, Alkandari A, Baker-Moffatt M, Dash J, Lyons-Amos M, Longcroft-Wheaton G, et al
Endoscopy. 2020
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is associated with a risk of bleeding. Bleeding is usually treated with diathermy, although this does carry a risk of mucosal thermal injury. Purastat is a topical hemostat that may be effective in controlling bleeding during ESD, thereby reducing the use of heat therapy. The aim of this study was to assess the reduction in heat therapy used in the interventional group (Purastat) compared with the control group. The secondary aims were to compare the procedure length, time for hemostasis, delayed bleeding rate, adverse events, and wound healing between the groups. METHODS This was a single-center randomized controlled trial of 101 patients undergoing ESD. Participants were randomized to a control group where diathermy was used to control bleeding or an interventional group where Purastat could be used. Follow-up endoscopy was performed at 4 weeks to assess wound healing. RESULTS There was a significant reduction in the use of heat therapy for intraprocedural hemostasis in the interventional group compared with controls (49.3 % vs. 99.6 %, P < 0.001). There were no significant differences in the procedure length, time for hemostasis, and delayed bleeding rate between the groups. Complete wound healing at 4 weeks was noted in 48.8 % of patients in the interventional group compared with 25.0 % of controls (P = 0.02). CONCLUSIONS This study has demonstrated that Purastat is an effective hemostat that can reduce the need for heat therapy for bleeding during ESD. It may also have a role in improving post-resection wound healing.
