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1.
Twenty-years of Embolization for Acute Lower Gastrointestinal Bleeding: A Meta-analysis of Rebleeding and Ischemia Rates
Yu, Q., Funaki, B., Ahmed, O.
The British journal of radiology. 2024
Abstract
BACKGROUND Transarterial embolization (TAE) for acute lower gastrointestinal bleeding (LGIB) can be technically challenging due to the compromise between achieving hemostasis and causing tissue ischemia. The goal of the present study is to determine its technical success, rebleeding, and post-embolization ischemia rates through meta-analysis of published literature in the last twenty-years. MATERIALS AND METHODS PubMed, Embase, and Cochrane Library databases were queried. Technical success, rebleeding, and ischemia rates were extracted. Baseline characteristics such as author, publication year, region, study design, embolization material, percentage of superselective embolization were retrieved. Subgroup analysis was performed based on publication time and embolization agent. RESULTS A total of 66 studies including 2121 patients who underwent embolization for acute LGIB were included. Endoscopic management was attempted in 34.5%. The pooled overall technical success, rebleeding, post-embolization ischemia rates were 97.0%, 20.7%, and 7.5%, respectively. Studies published after 2010 showed higher technical success rates (97.8% vs 95.2%), lower rebleeding rates (18.6% vs 23.4%), and lower ischemia rates (7.3% vs 9.7%). Compared to microcoils, NBCA was associated with a lower rebleeding rate (9.3% vs 20.8%) at the expense of a higher post-embolization ischemia rate (9.7% vs 4.0%). Coagulopathy (p = 0.034), inotropic use (p = 0.040), and malignancy (p = 0.002) were predictors of post-embolization rebleeding; hemorrhagic shock (p < 0.001), inotropic use (p = 0.026), malignancy (p < 0.001), coagulopathy (p = 0.002), blood transfusion (p < 0.001), and enteritis (p = 0.023) were predictors of mortality. Empiric embolization achieved a similarly durable hemostasis rate to targeted embolization (23.6% vs 21.1%) but a higher risk of post-embolization ischemia (14.3% vs 4.7%). CONCLUSION For LGIB, TAE has a favorable technical success rate and low risk of post-embolization ischemia. Its safety and efficacy profile has increased over the last decade. Compared to microcoils, NBCA seemed to offer a more durable hemostasis rate at the expense of higher ischemia risk. Due to the heterogeneity of currently available evidence, future prospective and comparative studies are warranted.
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2.
Efficacy of New Hemostatic Techniques in Nonvariceal Gastrointestinal Bleeding: A Systematic Review and Network Meta-analysis
Liu K, Gao L, Bai J, Wang L, Zhu S, Zhao X, Han Y, Liu Z
Journal of digestive diseases. 2023
Abstract
OBJECTIVE This systematic review and network meta-analysis aimed to assess the relative efficacy of currently multiple hemostatic modalities in nonvariceal gastrointestinal bleeding (NVGIB). BACKGROUND Nonvariceal gastrointestinal bleeding is a frequent medical condition with significant mortality and morbidity. There are currently multiple hemostatic modalities, but their relative efficacy is still unknown. METHODS Major databases including PubMed, EMBASE and the Cochrane Library were searched for studies that compared the relative efficacy of different hemostatic techniques for NVGIB (over-the-scope-clip (OTSC), hemostatic powder (HP) and conventional endoscopic treatment (CET)). The 30-day rebleeding rate was the primary outcome. We performed pairwise and network meta-analyses for all treatments. The heterogeneity and transitivity were evaluated. RESULTS Twenty-two studies were included. OTSC and HP + CET showed superior efficacy compared with CET (OTSC vs CET: RR, 0.42 [95% CI, 0.28-0.60]; HP + CET vs CET: RR, 0.40 [95% CI, 0.17-0.87]) while their relative efficacy had not detected any statistically significant difference (OTSC vs HP + CET: RR, 0.95 [95% CI, 0.38-2.31]) in the 30-day rebleeding rate. HP + CET was ranked highest in the network ranking estimate. In addition, the sensitivity analysis showed that it was not robust that OTSC was superior to CET in the short-term rebleeding rate and the initial hemostasis rate. None of the other comparisons found a statistically significant difference. CONCLUSIONS This systematic review and network meta- analysis showed that OTSC and HP + CET significantly reduced 30-day rebleeding rates compared to CET and had similar efficacy. This article is protected by copyright. All rights reserved.
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Seamguard Buttressing of the Staple Line During Laparoscopic Sleeve Gastrectomy Appears to Decrease the Incidence of Postoperative Bleeding, Leaks, and Reoperations. A Systematic Review and Meta-Analysis of Non-Randomized Comparative Studies
Diab AF, Alfieri S, Doyle W, Koussayer B, Docimo S, Sujka JA, DuCoin CG
Obesity surgery. 2023
Abstract
Leaks and bleeding are major acute postoperative complications following laparoscopic sleeve gastrectomy (LSG). Various staple line reinforcement (SLR) methods have been invented such as oversewing/suturing (OS/S), omentopexy/gastropexy (OP/GP), gluing, and buttressing. However, many surgeons do not use any type of reinforcement. On the other hand, surgeons who use a reinforcement method are often confused of what kind of reinforcement they should use. No robust and high-quality data supports the use of one reinforcement over the other or even supports the use of reinforcement over no-reinforcement. Therefore, SLR is a controversial topic that is worth our focus. The aim of this study is to compare the outcomes of LSG with versus without Seamguard buttressing of the staple line during LSG.
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4.
Over-the-Scope Clips Versus Standard Endoscopic Treatment for First Line Therapy of Non-variceal Upper Gastrointestinal Bleeding: Systematic Review and Meta-Analysis
Faggen AE, Kamal F, Lee-Smith W, Khan MA, Sharma S, Acharya A, Ahmed Z, Farooq U, Bayudan A, McLean R, et al
Digestive diseases and sciences. 2023
Abstract
BACKGROUND AND AIMS Over-The-Scope Clips (OTSC) use have shown promising results for first line treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). We conducted this meta-analysis to compare outcomes in patients treated with OTSC versus standard endoscopic intervention for first line endoscopic treatment of NVUGIB. METHODS We reviewed several databases from inception to December 9, 2022 to identify studies comparing OTSC and standard treatments as the first line treatment for NVUGIB. The outcomes assessed included re-bleeding, initial hemostasis, need for vascular embolization, mortality, need for repeat endoscopy, 30 day readmission rate, and need for surgery. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using random effect model. Heterogeneity was assessed by I(2) statistic. RESULTS We included 11 studies with 1608 patients (494 patients in OTSC group and 1114 patients in control group). OTSC use was associated with significantly lower risk of re-bleeding (RR, 0.58; 95% CI 0.41-0.82). We found no significant difference in rates of initial hemostasis (RR, 1.05; 95% CI 0.99- 1.11), vascular embolization rates (RR, 0.93; 95% CI 0.40- 2.13), need for repeat endoscopy (RR, 0.78; 95% CI 0.40-1.49), 30 day readmission rate (RR, 0.59; 95% CI 0.17-2.01), need for surgery (RR, 0.81; 95% CI 0.29-2.28) and morality (RR, 0.69; 95% CI 0.38-1.23). CONCLUSIONS OTSC are associated with significantly lower risk of re-bleeding compared to standard endoscopic treatments when used as first line endoscopic therapy for NVUGIB.
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5.
Topical hemostatic agents in the management of upper gastrointestinal bleeding: a meta-analysis
Alali AA, Moosavi S, Martel M, Almadi M, Barkun AN
Endoscopy international open. 2023;11(4):E368-e385
Abstract
Background and study aims Novel topical hemostatic agents have shown promising results in treating patients with non-variceal upper gastrointestinal bleeding (NVUGIB). However, data are limited even in published meta-analyses as to their role, especially compared to conventional endoscopic approaches. The aim of this study was to perform a highly comprehensive systematic review assessing the effectiveness of topical hemostatic agents in UGIB in different clinical settings. Methods We performed a literature search of OVID MEDLINE, EMBASE, and ISI Web of Knowledge databases through September 2021. Studies assessing the efficacy of topical hemostatic agents in UGIB were included. Main outcomes were immediate hemostasis and overall rebleeding. Results A total of 980 citations were identified and 59 studies with a total of 3,417 patients were included in the analysis. Immediate hemostasis was achieved in 93 % (91 %; 94 %), with similar results according to etiology (NVUGIB vs. variceal), topical agent used, or treatment strategy (primary vs. rescue). The overall rebleeding rate was 18 % (15%; 21 %) with the majority of rebleeds occurring in the first 7 days. Among comparative studies, topical agents achieved immediate hemostasis more often than standard endoscopic modalities (OR 3.94 [1.73; 8.96), with non-different overall rebleeding odds (OR 1.06 [0.65; 1.74]). Adverse events occurred in 2 % (1 %; 3 %). Study quality was overall low to very low. Conclusions Topical hemostatic agents are effective and safe in the management of UGIB with favorable outcomes when compared to conventional endoscopic modalities across a variety of bleeding etiologies. This is especially true in novel subgroup analyses that assessed immediate hemostasis and rebleeding among RCTs and in malignant bleeding. Due to methodological limitations of available data, additional studies are needed to ascertain their effectiveness more confidently in the management of patients with UGIB.
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6.
Tranexamic acid for percutaneous nephrolithotomy
Cleveland, B., Norling, B., Wang, H., Gandhi, V., Price, C. L., Borofsky, M. S., Pais, V., Dahm, P.
The Cochrane database of systematic reviews. 2023;10(10):Cd015122
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Editor's Choice
Abstract
BACKGROUND Percutaneous nephrolithotomy (PCNL) is the gold standard for the treatment of large kidney stones but comes with an increased risk of bleeding compared to other treatments, such as ureteroscopy and shock wave lithotripsy. Tranexamic acid (TXA) is an antifibrinolytic agent that has been used to reduce bleeding complications in other settings. OBJECTIVES To assess the effects of TXA in individuals with kidney stones undergoing PCNL. SEARCH METHODS We performed a comprehensive literature search of the Cochrane Library, PubMed (including MEDLINE), Embase, Scopus, Global Index Medicus, trials registries, other sources of the grey literature, and conference proceedings. We applied no restrictions on the language of publication nor publication status. The latest search date was 11 May 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared treatment with PCNL with administration of TXA to placebo (or no TXA) for patients ≥ 18 years old. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data. Primary outcomes were: blood transfusion, stone-free rate (SFR), and thromboembolic events (TEEs). Secondary outcomes were: adverse events (AEs), secondary interventions, major surgical complications, minor surgical complications, unplanned hospitalizations or readmissions, and hospital length of stay (LOS). We performed statistical analyzes using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach using a minimally contextualized approach with predefined thresholds for minimally clinically important differences (MCIDs). MAIN RESULTS We analyzed 10 RCTs assessing the effect of systemic TXA in PCNL versus placebo (or no TXA) with 1883 randomized participants. Eight studies were published as full text. One was published in abstract proceedings, but it was separated into two separate studies for the purpose of our analyzes. Average stone surface area ranged 3.45 to 6.62 cm(2). We also found a single RCT published in full text assessing the effects of topical TXA in PCNL versus placebo (or no TXA) with 400 randomized participants, the results of which are further described in the review. Here we focus only on the results of TXA used systemically. Blood transfusion - Based on a representative baseline risk of 5.7% for blood transfusions taken from a large presentative observational studies, systemic TXA may reduce blood transfusions (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.27 to 0.76; I(2) = 28%; 9 studies, 1353 participants; low CoE). We assumed an MCID of ≥ 2%. Based on 57 participants per 1000 with placebo (or no TXA) being transfused, this corresponds to 31 fewer (from 42 fewer to 14 fewer) participants being transfused per 1000. Stone-free rate - Based on a representative baseline risk of 75.7% for SFR, systemic TXA may increase SFRs (RR 1.11, 95% CI 0.98 to 1.27; I(2) = 62%; 4 studies, 603 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 757 participants per 1000 being stone free with placebo (or no TXA), this corresponds to 83 more (from 15 fewer to 204 more) stone-free participants per 1000. Thromboembolic events - There is probably no difference in TEEs (risk difference (RD) 0.00, 95% CI -0.01 to 0.01; I(2) = 0%; 6 studies, 841 participants; moderate CoE). We assumed an MCID of ≥ 2%. Since there were no thromboembolic events in intervention and/or control groups in 5 out of6 studies, we opted to assess a risk difference with systemic TXA for this outcome. Adverse events - Systemic TXA may increase AEs (RR 5.22, 95% CI 0.52 to 52.72; I(2) = 75%; 4 studies, 602 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 23 participants per 1000 with placebo (or no TXA) having an adverse event, this corresponds to 98 more (from 11 fewer to 1000 more) participants with adverse events per 1000. Secondary interventions - Systemic TXA may have little to no effect on secondary interventions (RR 1.15, 95% CI 0.84 to 1.57; I(2) = 0%; 2 studies, 319 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 278 participants per 1000 with placebo (or no TXA) having a secondary intervention, this corresponds to 42 more (from 44 fewer to 158 more) participants with secondary interventions per 1000. Major surgical complications - Based on a representative baseline risk for major surgical complications of 4.1%, systemic TXA may reduce major surgical complications (RR 0.36, 95% CI 0.21 to 0.62; I(2) = 0%; 5 studies, 733 participants; moderate CoE). We assumed an MCID of ≥ 2%. Based on 41 participants per 1000 with placebo (or no TXA) having a major surgical complication, this corresponds to 26 fewer (from 32 fewer to 16 fewer) participants with major surgical complications per 1000. Minor surgical complications - Systemic TXA may reduce minor surgical complications (RR 0.71, 95% CI 0.45 to 1.10; I(2) = 76%; 5 studies, 733 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 396 participants per 1000 with placebo (or no TXA) having a minor surgical complication, this corresponds to 115 fewer (from 218 fewer to 40 more) participants with minor surgical complications per 1000. Unplanned hospitalizations or readmissions - We are very uncertain how unplanned hospitalizations or readmissions are affected (RR 1.55, 95% CI 0.45 to 5.31; I(2) = not applicable; 1 study, 189 participants; very low CoE). We assumed an MCID of ≥ 2%. Hospital length of stay - Systemic TXA may reduce hospital LOS (mean difference 0.52 days lower, 95% CI 0.93 lower to 0.11 lower; I(2) = 98%; 7 studies, 1151 participants; low CoE). We assumed an MCID of ≥ 0.5 days. AUTHORS' CONCLUSIONS Based on 10 RCTs with substantial methodological limitations that lowered all CoE of effect, we found that systemic TXA in PCNL may reduce blood transfusions, major and minor surgical complications, and hospital LOS, as well as improve SFRs; however, it may increase AEs. We are uncertain about the effects of systemic TXA on other outcomes. Findings of this review should assist urologists and their patients in making informed decisions about the use of TXA in the setting of PCNL.
PICO Summary
Population
Patients with kidney stones undergoing percutaneous nephrolithotomy (PCNL), (10 randomised controlled trials (RCTs), n= 1,883).
Intervention
Tranexamic acid.
Comparison
Placebo or no tranexamic acid.
Outcome
The primary outcomes were: blood transfusion, stone-free rate, and thromboembolic events. Based on 10 RCTs with substantial methodological limitations that lowered all certainty of evidence of effect, the authors found that systemic tranexamic acid in PCNL may reduce blood transfusions, major and minor surgical complications, and hospital length of stay, as well as improve stone-free rates; however, it may increase adverse events. The authors were uncertain about the effects of systemic TXA on other outcomes.
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Tranexamic acid for percutaneous nephrolithotomy: an abridged Cochrane Review
Cleveland, B., Norling, B., Wang, H., Gandhi, V., Price, C. L., Borofsky, M., Pais, V., Dahm, P.
BJU international. 2023
Abstract
PURPOSE To assess the effects of tranexamic acid (TXA) in individuals with kidney stones undergoing percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS We performed a literature search of Cochrane Library, PubMed (including MEDLINE), Embase, Scopus, Global Index Medicus, trials registries, grey literature, and conference proceedings. We included randomized controlled trials (RCT) that compared treatment with PCNL with administration of TXA to placebo (or no TXA) for patients ≥18 years old. Two review authors independently classified studies and abstracted data. Primary outcomes were blood transfusion, stone free rate (SFR), thromboembolic events (TEE). We rated the certainty of evidence (CoE) according to the GRADE approach using a minimally contextualized approach with predefined thresholds for minimally clinically important differences (MCID). RESULTS We included 10 RCTs assessing the effect of systemic TXA in PCNL versus placebo (or no TXA). Eight studies were published as full-text. Based on an adjusted baseline risk of blood transfusion of 5.7%, systemic TXA may reduce blood transfusions (RR 0.45, 95% CI 0.27 to 0.76). Based on an adjusted baseline SFR of 75.7%, systemic TXA may increase SFR (RR 1.11, 95% CI 0.98 to 1.27). There is probably no difference in TEEs (risk difference (RD) 0.00, 95% CI -0.01 to 0.01). Systemic TXA may increase AE (RR 5.22, 95% CI 0.52 to 52.72). Systemic TXA may have little to no effect on secondary interventions (RR1.15, 95% CI 0.84 to 1.57). The CoE for most outcomes was assessed as low or very low. CONCLUSIONS Based on a body of evidence of 10 RCTs, we found that systemic TXA in PCNL may reduce blood transfusions, major surgical complications, and hospital LOS, as well as improve SFR; however, it may increase AE. These findings should inform urologists and their patients in making informed decisions about the use of TXA in the setting of PCNL.
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Efficacy of self-assembling peptide in mitigating delayed bleeding after advanced endoscopic resection of gastrointestinal lesions: A meta-analysis
Gopakumar, H., Vohra, I., Sharma, N. R., Puli, S. R.
Endoscopy international open. 2023;11(5):E553-e560
Abstract
Background and study aims Advanced endoscopic resection techniques carry a risk of delayed bleeding (DB). A novel fully synthetic self-assembling peptide (SAP) has shown promising results in mitigating this risk. In this meta-analysis, we evaluated all available data and analyzed the effectiveness of SAP in reducing DB after advanced endoscopic resection of gastrointestinal luminal lesions. Patients and methods Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the use of SAP solution in patients undergoing advanced endoscopic resection of gastrointestinal lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models. Results The initial search identified 277 studies, of which 63 relevant articles were reviewed. The final analysis included data from six studies comprising 307 patients that met inclusion criteria. The pooled rate of DB was 5.73 % (95 % confidence interval [CI] = 3.42-8.59). Mean patient age was 69.40 years ± 1.82. The weighted mean size of resected lesions was 36.20 mm (95 % CI = 33.37-39.02). Endoscopic submucosal dissection was used in 72.69 % (95 % CI = 67.62-77.48), while endoscopic mucosal resection was used in 26.42 % (95 % CI = 21.69-31.44) of the procedures. Among the 307 patients, 36 % were on antithrombotic medications. No adverse events (AEs) were attributable to using SAP, with a pooled rate of 0.00 % (95 % CI = 0.00-1.49). Conclusions SAP solution appears promising in reducing post-procedural DB after advanced endoscopic resection of high-risk gastrointestinal lesions with no reported AEs.
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New Alternative? Self-Assembling Peptide in Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis
Dhindsa, B. S., Tun, K. M., Scholten, K. J., Deliwala, S., Naga, Y., Dhaliwal, A., Ramai, D., Saghir, S. M., Dahiya, D. S., Chandan, S., et al
Digestive diseases and sciences. 2023;68(9):3694-3701
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a common and potentially fatal condition with all-cause mortality ranging from 3 to 10%. Endoscopic therapy traditionally involves mechanical, thermal, and injection therapies. Recently, self-assembling peptide (SAP) has become increasingly available in the United States. When applied to an affected area, this gel forms an extracellular matrix-type structure allowing for hemostasis. This is the first systematic review and meta-analysis to assess the safety and efficacy of this modality in GIB. METHODS We performed a comprehensive literature search of major databases from inception to Nov 2022. The primary outcomes assessed were the success of hemostasis, rebleeding rates, and adverse events. The secondary outcomes assessed were successful hemostasis with monotherapy with SAP and combined therapy, which may include mechanical, injection, and thermal therapies. Pooled estimates were calculated using random-effects models with a 95% confidence interval (CI). RESULTS The analysis included 7 studies with 427 patients. 34% of the patients were on anticoagulation or antiplatelet agents. SAP application was technically successful in all patients. The calculated pooled rate of successful hemostasis was 93.1% (95% confidence interval (CI) 84.7-97.0, I(2) = 73.6), and rebleeding rates were 8.9% (95% CI 5.3-14.4, I(2) = 55.8). The pooled rates of hemostasis with SAP monotherapy and combined therapy were similar. No adverse events were noted related to SAP. CONCLUSION SAP appears to be a safe and effective treatment modality for patients with GIB. This modality provides an added advantage of improved visualization over the novel spray-based modalities. Further, prospective, or randomized controlled trials are needed to validate our findings.
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10.
Minimally invasive versus open total pancreatectomy: a systematic review and meta-analysis
Chen, L., Xia, N., Wang, Z., Junjie, X., Tian, B.
International journal of surgery (London, England). 2023;109(7):2058-2069
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Abstract
OBJECTIVE The aim of this study was to perform a systematic review and meta-analysis on the safety and effectiveness regarding outcomes of minimally invasive total pancreatectomy (MITP) versus open total pancreatectomy (OTP). BACKGROUND Total pancreatectomy is a complicated operation in abdominal surgery. The flexibility of minimally invasive surgery offers a new surgical approach to this technology. At present, there is little research on MITP, and its advantages over OTP remain uncertain. METHODS A systematic literature review and meta-analysis was conducted basing on comparative studies between MITP and OTP from January 1943 to November 2022. Intraoperative outcomes and postoperative outcomes were assessed. Pooled odds ratios (ORs) and mean differences with a 95% CI were calculated using fixed-effect or random-effect models under heterogeneity. RESULTS Seven studies with a total of 4275 patients were included. The major morbidity in the MITP group was significant lower (OR 0.50, 95% CI: 0.30-0.84, P=0.008, I²= 0%) than OTP group. At the same time, comparing with OTP, the MITP group had lower estimated blood loss (MD -362.50, 95% CI -641.34 to -83.66, P=0.01, I²=96%) and lower intraoperative transfusion rate (OR 0.36, 95% CI 0.16-0.84, P=0.02, I²=0%). There were no significant differences between the MITP and OTP groups for other outcomes. CONCLUSIONS The results suggested that MITP was associated with lower major morbidity, estimated blood loss, and intraoperative transfusion rate comparing with OTP. However, the further evidence with a better design is required.