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What is the optimal management of thromboprophylaxis after liver transplantation regarding prevention of bleeding, hepatic artery or portal vein thrombosis? A systematic review of the literature and expert panel recommendations
Kirchner VA, O'Farrell B, Imber C, McCormack L, Northup PG, Song GW, Spiro M, Raptis DA, Durand F
Clinical transplantation. 2022;:e14629
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Abstract
BACKGROUND A key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding. (CRD42021244288) RESULTS Of the 2,478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post-LT, yet it did not increase the risk of bleeding. CONCLUSIONS Based on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT. This article is protected by copyright. All rights reserved.
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Clinical Outcomes of Negative Balloon-Assisted Enteroscopy for Obscure Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis
Shao XD, Shao HT, Wang L, Zhang YG, Tian Y
Frontiers in medicine. 2022;9:772954
Abstract
BACKGROUND For patients with obscure gastrointestinal bleeding (OGIB), finding the bleeding site is challenging. Balloon-assisted enteroscopy (BAE) has become the preferred diagnostic modality for OGIB. The long-term outcome of patients with negative BAE remains undefined. The present study aimed to evaluate the long-term outcomes of patients with negative BAE results for OGIB and to clarify the effect of further investigations at the time of rebleeding with a systematic review and meta-analysis of the available cohort studies. METHODS Studies were searched through the PubMed, EMBASE, and Cochrane library databases. The following indexes were analyzed: rebleeding rate after negative BAE, rebleeding rate after different follow-up periods, the proportion of patients who underwent further evaluation after rebleeding, the percentage of patients with identified rebleeding sources, and the percentage of patients with rebleeding sources in the small intestine. Heterogeneity was assessed using the I(2) test. RESULTS Twelve studies that involved a total of 407 patients were included in the analysis. The pooled rebleeding rate after negative BAE for OGIB was 29.1% (95% CI: 17.2-42.6%). Heterogeneity was significant among the studies (I(2) = 88%; p < 0.0001). The Chi-squared test did not show a difference in rebleeding rates between the short and long follow-up period groups (p = 0.142). The pooled proportion of patients who underwent further evaluation after rebleeding was 86.1%. Among the patients who underwent further evaluation, rebleeding sources were identified in 73.6% of patients, and 68.8% of the identified rebleeding lesions were in the small intestine. CONCLUSION A negative result of BAE in patients with OGIB indicates a subsequently low risk of rebleeding. Further evaluation should be considered after rebleeding.
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A predictive model for blood transfusion during liver resection
Cao B, Hao P, Guo W, Ye X, Li Q, Su X, Li L, Zeng J
European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2022
Abstract
BACKGROUND A predictive model that can identify patients who are at increased risk of intraoperative blood transfusion could guide preoperative transfusion risk counseling, optimize health care resources, and reduce medical costs. Although previous studies have identified some predictors for particular populations, there is currently no existing model that uses preoperative variables to accurately predict blood transfusion during surgery, which could help anesthesiologists optimize intraoperative anesthetic management. METHODS We collected data from 582 patients who underwent elective liver resection at a university-affiliated tertiary hospital between January 1, 2018, and December 31, 2020. The data set was then randomly divided into a training set (n = 410) and a validation set (n = 172) at a 7:3 ratio. The least absolute shrinkage and selection operating regression model was used to select the optimal feature, and multivariate logistic regression analysis was applied to construct the transfusion risk model. The concordance index (C-index) and the area under the receiver operating characteristic (ROC) curve (AUC) were used to evaluate the discrimination ability, and the calibration ability was assessed with calibration curves. In addition, we used decision curve analysis (DCA) to estimate the clinical application value. For external validation, the test set data were employed. RESULTS The final model had 8 predictor variables for intraoperative blood transfusion, which included the following: preoperative hemoglobin level, preoperative prothrombin time >14 s, preoperative total bilirubin >21 μmol/L, respiratory diseases, cirrhosis, maximum lesion diameter >5 cm, macrovascular invasion, and previous abdominal surgery. The model showed a C-index of 0.834 (95% confidence interval, 0.789-0.879) for the training set and 0.831 (95% confidence interval, 0.766-0.896) for the validation set. The AUCs were 0.834 and 0.831 for the training and validation sets, respectively. The calibration curve showed that our model had good consistency between the predictions and observations. The DCA demonstrated that the transfusion nomogram was reliable for clinical applications when an intervention was decided at the possible threshold across 1%-99% for the training set. CONCLUSION We developed a predictive model with excellent accuracy and discrimination ability that can help identify those patients at higher odds of intraoperative blood transfusion. This tool may help guide preoperative counseling regarding transfusion risk, optimize health care resources, reduce medical costs, and optimize anesthetic management during surgery.
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Strategic response to bleeding in laparoscopic hepato-pancreato-biliary surgery: an intraoperative checklist
Vega, EA, Salehi O, Loewenthal JV, Kutlu OC, Vellayappan U, Freeman R, Pomposelli F, Asbun HJ, Gayet B, Conrad C
HPB : the official journal of the International Hepato Pancreato Biliary Association. 2021
Abstract
BACKGROUND The aim is to develop and test the utility of an event-initiated, team-based check list to optimize the response to bleeding during laparoscopic HPB surgery. METHODS To build a checklist for managing bleeding events, we conducted a systematic review. Using nominal group technique (NGT), a checklist consisting of four domains was developed. Following team-based training of anesthesia and surgical staff, the checklist was implemented. HPB cases before and after implementation of the checklist were compared for adverse outcomes, bleeding complications, and transfusions. RESULTS NGT identified four domains: Communicate Control, Expose, and Repair under which the checklist was organized. Supplemental Video for a detailed review of how each domain was applied to a specific case example. We compared 169 HPB cases before to 53 cases after implementation. We found a significant decrease in mean EBL (from 518 ± 852.8 to 151.5 ± 221.7 ml (P = 0.001)) for cases performed after implementation of the checklist and a trends toward less volume of pRBC transfused (2.7 ± 2.5 vs 2.3 ± 1.7 units/per patient, P = 0.611) and transfusion rates (22% vs 11%, P = 0.703). CONCLUSION An event-initiated, team-based response to an adverse bleeding event during laparoscopic HPB surgery correlates with positive effects on bleeding management, and transfusion rates.
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A Literature Review to Assess Blood Loss in Minimally Invasive Liver Surgery Versus in Open Liver Resection
Elmahi E, Salama Y, Cadden F
Cureus. 2021;13(6):e16008
Abstract
Aim and objectives The aim of the study was to assess the amount of blood loss in minimally invasive hepatectomy and open liver resection for both benign and neoplastic conditions. Introduction Minimally invasive surgery has progressively developed to a stage where once-novel and highly specialized surgical techniques are now common practice. Colorectal surgery is the key example that has shown minimally invasive surgery as highly beneficial. Successes in the colorectal laparoscopic approach have now been integrated into the speciality of hepatopancreaticobiiary (HPB) surgery. In this review, we will compare the amount of blood loss in minimally invasive liver resection with the more traditional approach of open liver resection. Methods A literature review was conducted which included the length of patient mobilization as a postoperative complication following laparoscopic and open liver resections. Medline, PubMed, and Cochrane were accessed to review previously published studies. Twelve studies were selected, and all of them were in English, ranged from the year 2000 to 2020. Results Eleven out of the 12 included studies indicated that minimally invasive liver resection is associated with reduced blood loss. Conclusion In comparing both minimally invasive liver resection and classic open surgery, minimally invasive liver resection was shown to have reduced blood loss; this was seen in both malignant and benign tumours. Therefore, laparoscopic liver resection could be favoured over the classical open approach to avoid excessive blood loss intra-operatively.
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A systematic review of post-pancreatectomy haemorrhage management stratified according to ISGPS grading
Maccabe TA, Robertson HF, Skipworth J, Rees J, Roberts K, Pathak S
HPB : the official journal of the International Hepato Pancreato Biliary Association. 2021
Abstract
BACKGROUND Morbidity and mortality from post-pancreatectomy haemorrhage (PPH) remains high. The International Study Group of Pancreatic Surgery (ISGPS) published guidelines to standardise definitions of PPH severity, management and reporting. This study aimed to i) identify the number of studies reporting PPH using ISGPS guidelines (Grade A, B or C) and ii) describe treatment modality success by grade. METHODS A systematic literature review was performed, identifying studies reporting PPH by ISGPS Grade and their subsequent management. RESULTS Of 62 studies reporting on PPH management, 17 (27.4%) stratified by ISGPS guidelines and included 608 incidences of PPH: 48 Grade A, 274 Grade B (62 early, 166 late, 46 unspecified) and 286 Grade C. 96% of Grade A PPH were treated conservatively. Of 62 early Grade B, 54.8% were managed conservatively and 37.1% surgically. Late Grade B were managed non-operatively in 25.3% (42/166), with successful endoscopy in 90.9% (10/11) and angiography in 90.3% (28/31). In Grade C, endoscopic treatment was successful in 64.4% (29/45) and angiography in 90.8% (108/119). Surgical intervention was required in 43.5% early Grade B, 7.8% late Grade B and 33.2% Grade C. CONCLUSION PPH grading is underreported and despite guidelines, inconsistencies remain when using definitions and reporting of outcomes.
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Procedure-related risk factors for bleeding after percutaneous transhepatic biliary drainage: A systematic review and meta-analysis
Lee YT, Yen KC, Liang PC, Wu CH
Journal of the Formosan Medical Association = Taiwan yi zhi. 2021
Abstract
BACKGROUND/PURPOSE Bleeding is the most dreaded complication after percutaneous transhepatic biliary drainage (PTBD). Clarifying the risk factors of bleeding can reduce the morbidity and mortality rates of PTBD. However, the procedure-related risk factors for bleeding after PTBD are still controversial. Therefore, this systematic review and meta-analysis were performed to identify procedure-related risk factors of bleeding after PTBD. METHODS PubMed, Cochrane database, and Google Scholar were searched for published studies until 1st May 2021. Inclusion criteria were: studies associated with bleeding complications after PTBD and with sufficient data to compare different procedure-related factors for bleeding. Sources of bias were assessed using the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool for randomised trials. Probable procedure-related risk factors were evaluated and outcomes were expressed in the case of dichotomous variables, as an odds ratio (OR) (with a 95% confidence interval, (CI)). RESULTS Eleven studies were included in the meta-analysis. There was no significant difference in bleeding rates with respect to the side of PTBD (left/right, OR = 1.10, 95% CI: 0.68-1.76), the insertion level of bile duct (central/peripheral, OR = 1.39, 95% CI: 0.82-2.35), and the usage of ultrasound guidance (OR: 1.25, 95% CI: 0.60-2.60). A subgroup analysis revealed a left-sided approach that resulted in more hepatic arterial injuries than the right-sided approach (left/right, OR = 1.93, 95% CI: 1.32-2.83). CONCLUSION Left-sided approach is a risk factor for hepatic arterial injuries after PTBD.
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Risk factors for hemorrhage requiring embolization after percutaneous nephrolithotomy: a meta-analysis
Li Z, Wu A, Liu J, Huang S, Chen G, Wu Y, Chen X, Tan G
Transl Androl Urol. 2020;9(2):210-217
Abstract
Background: The aim of this meta-analysis was to systematically review and identify the risk factors for severe hemorrhage after percutaneous nephrolithotomy (PCNL). Methods: We searched the PubMed and EMBASE database for literature related to the risk factors of severe hemorrhage after PCNL requiring angiography and embolization through to September 2019. The necessary data for each eligible study were extracted by 2 independent reviewers. The Newcastle-Ottawa Scale (NOS) was used for assessing the methodological quality of the included studies. Statistical analyses were conducted using Comprehensive Meta-Analysis version 2 to identify whether there was a statistical association between risk factors and severe hemorrhage post-PCNL. Results: The results of this meta-analysis showed that urinary tract infection (UTI) (OR =1.98, 95% CI, 1.21-3.26, P=0.007), diabetes mellitus (OR =4.07, 95% CI, 1.83-9.06, P=0.001), staghorn stone (OR =3.49, 95% CI, 1.25-9.76, P=0.017), and multiple tracts (OR =2.09, 95% CI, 1.33-3.28, P=0.001) were independent risk factors for severe hemorrhage post-PCNL, while hypertension (OR =1.18, 95% CI, 0.58-2.42, P=0.65) showed no significant statistical difference. Conclusions: Urologists should focus on the above identified risk factors for severe hemorrhage post-PCNL, including UTI, diabetes mellitus, staghorn stone, and multiple tracts. More high-quality studies with larger sample sizes are needed to validate these conclusions.