1.
Early-TIPS Versus Current Standard Therapy for Acute Variceal Bleeding in Cirrhosis Patients: A Systemic Review With Meta-analysis
Li S, Zhang C, Lin LL, Wang Q, Zuo HX, Zhan AL, Luo J, Niu YM, Zhong GQ
Front Pharmacol. 2020;11:603
Abstract
Background: The survival of early placement (within 72h after admission) of transjugular intrahepatic portosystemic shunts (early-TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) is controversial. Objectives: We performed a systemic review and meta-analysis to assess whether early-TIPS could improve survival in patients with cirrhosis and acute variceal bleeding. Methods: A systematic search of the literature was conducted in PubMed, EMBASE, and Cochrane Library published before 25 June 2019 for eligible studies that compared early-TIPS with a combination of endoscopic variceal ligation (EVL) and pharmacotherapy in the therapeutic effect in AVB patients. Results: A total of five studies with 1,754 participants were enrolled. The early-TIPS demonstrated a significant improvement in prevention of treatment failure (OR=0.11,95%CI=0.05-0.23), 6-weeks mortality (OR=0.24,95%CI=0.13-0.46), rebleeding within 6 weeks (OR=0.21,95%CI=0.12-0.36), rebleeding within 1 year (OR=0.16,95%CI=0.07-0.36), new or worsening ascites (OR=0.33,95%CI=0.21-0.53), except in encephalopathy (OR=1.29,95%CI=0.996-1.67). For 1-year mortality, a significant prior effect was also observed in early-TIPS (OR=0.64,95%CI=0.46-0.90), and the beneficial effect in Child-Pugh C patients (OR=0.35,95%CI=0.18-0.68) was equal to Child-Pugh B patients (OR=0.34,95%CI=0.25-0.58). No difference in liver transplantation and mortality caused by liver failure was observed. Conclusions: Early covered-TIPS could be recommended for the management of AVB patients in cirrhosis demonstrating a significant improvement in treatment failure, both short- and long-term mortality, rebleeding risk, and new or worsening ascites compared to standard therapy, especially for high-risk AVB patients. It will also apply to patients with Child-Pugh A until solutions to prevent hepatic encephalopathy in future research are found.
2.
Use of urinary balloon catheter to prevent postoperative bleeding after ultrasound-guided vacuum-assisted breast biopsy
Lian ZQ, Yu HY, Zhang AQ, Xie SM, Wang Q
The breast journal. 2019
Abstract
Postoperative bleeding is the most frequent serious complications after vacuum-assisted breast biopsy (VABB). The aim of this study was to evaluate the clinical effect of using urinary balloon catheter to prevent postoperative bleeding after ultrasound-guided VABB. From May 2016 to June 2018, 324 patients who underwent ultrasound-guided VABB were randomized into the study group and control group. In the study group, an urinary balloon catheter was inserted into the excision cavity to prevent bleeding and hematoma. In the control group, compression with thorax pressure bandage was used for hemostasis. Postoperative subcutaneous ecchymosis and hematoma were recorded and compared between the two groups. The rates of postoperative ecchymosis and hematoma in the study group were significantly lower than that in the control group (5.6% vs 13.0%, P < .05; 8.0% vs 20.4%, P < .05). Among patients with lesions ≤1.5 cm, the rates of postoperative ecchymosis and hematoma were 2.9% and 4.3% in the study group, 6.5% and 11.7% in the control group, but there was no statistically significant difference between the two groups (P > .05). Among patients with lesions >1.5 cm, the rates of postoperative ecchymosis and hematoma in the study group were significantly lower than that in the control group (7.6% vs 18.8%, P < .05; 10.9% vs 28.2%, P < .05). Hemostasis with balloon urinary catheter is a safe and effective method to prevent postoperative bleeding after VABB.
3.
Early TIPS with covered stents versus standard treatment for acute variceal bleeding in patients with advanced cirrhosis: a randomised controlled trial
Lv Y, Yang Z, Liu L, Li K, He C, Wang Z, Bai W, Guo W, Yu T, Yuan X, et al
The lancet. Gastroenterology & hepatology. 2019
Abstract
BACKGROUND The survival benefit of early placement of transjugular intrahepatic portosystemic shunts (TIPS) in patients with cirrhosis and acute variceal bleeding is controversial. We aimed to assess whether early TIPS improves survival in patients with advanced cirrhosis and acute variceal bleeding. METHODS We did an investigator-initiated, open-label, randomised controlled trial at an academic hospital in China. Consecutive patients with advanced cirrhosis (Child-Pugh class B or C) and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy were randomly assigned (2:1) to receive either early TIPS (done within 72 h after initial endoscopy [early TIPS group]) or standard treatment (vasoactive drugs continued to day 5, followed by propranolol plus endoscopic band ligation for the prevention of rebleeding, with TIPS as rescue therapy when needed [control group]). Randomisation was done by web-based randomisation system using a Pocock and Simon's minimisation method with Child-Pugh class (B vs C) and presence or absence of active bleeding as adjustment factors. The primary outcome was transplantation-free survival, analysed in the intention-to-treat population, excluding individuals subsequently found to be ineligible for enrolment. This study is registered with ClinicalTrials.gov, number NCT01370161, and is completed. FINDINGS From June 26, 2011, to Sept 30, 2017, 373 patients were screened and 132 patients were randomly assigned to the early TIPS group (n=86) or to the control group (n=46). After exclusion of three individuals subsequently found to be ineligible for enrolment (two patients in the early TIPS group with non-cirrhotic portal hypertension or hepatocellular carcinoma, and one patient in the control group due to non-cirrhotic portal hypertension), 84 patients in the early TIPS group and 45 patients in the control group were included in the intention-to-treat population. 15 (18%) patients in the early TIPS group and 15 (33%) in the control group died; two (2%) patients in the early TIPS group and one (2%) in the control group underwent liver transplantation. Transplantation-free survival was higher in the early TIPS group than in the control group (hazard ratio 0.50, 95% CI 0.25-0.98; p=0.04). Transplantation-free survival at 6 weeks was 99% (95% CI 97-100) in the early TIPS group compared with 84% (75-96; absolute risk difference 15% [95% CI 5-48]; p=0.02) and at 1 year was 86% (79-94) in the early TIPS group versus 73% (62-88) in the control group (absolute risk difference 13% [95% CI 2-28]; p=0.046). There were no significant differences between the two groups in the incidence of hepatic hydrothorax (two [2%] of 84 patients in the early TIPS group vs one [2%] of 45 in the control group; p=0.96), spontaneous bacterial peritonitis (one [1%] vs three [7%]; p=0.12), hepatic encephalopathy (29 [35%] vs 16 [36%]; p=1.00), hepatorenal syndrome (four [5%] vs six [13%]; p=0.10), and hepatocellular carcinoma (four [5%] vs one [2%]; p=0.68). There was no significant difference in the number of patients who experienced other serious adverse events (ten [12%] vs 11 [24%]; p=0.07) or non-serious adverse events (21 [25%] vs 19 [42%]; p=0.05) between groups. INTERPRETATION Early TIPS with covered stents improved transplantation-free survival in selected patients with advanced cirrhosis and acute variceal bleeding and should therefore be preferred to the current standard of care. FUNDING National Natural Science Foundation of China, National Key Technology R&D Program, Optimized Overall Project of Shaanxi Province, Boost Program of Xijing Hospital.
4.
A network meta-analysis of updated haemostatic strategies for hysterectomy
Guo T, Ren L, Wang Q, Li K
International Journal of Surgery (London, England). 2016;35:187-195.
Abstract
OBJECTIVE To determine the best haemostatic strategy for hysterectomy through a network meta-analysis. METHODS We conducted a systematic literature search of the PubMed, Embase, and Cochrane Library databases and extracted data from randomized controlled trials comparing haemostatic strategies for hysterectomy. Direct comparisons and network meta-analyses were conducted in RevMan and ADDIS. Consistency models were established to identify the differences among different haemostatic strategies, and cumulative probability was used to rank the included strategies. Inconsistencies were also tested using node-splitting models. RESULTS Twenty studies from 16 articles (2 articles contained 3 studies each) comprising 1392 patients were included. Direct meta-analysis showed that the LigaSure (SMD = -1.42 [-2.39, -0.44], P = 0.004), bipolar vessel sealing systems (BVSS) (SMD = -0.35 [-0.66, -0.03], P = 0.03), and pituitrin (SMD = -2.13 [-4.14, -0.13], P = 0.04) applications were effective haemostatic strategies. Based on the network meta-analysis and related subgroup analysis of different surgical procedures, the results showed that the application of pituitrin seemed to be the best haemostatic method for hysterectomy (Rank P = 0.64), especially for vaginal hysterectomy (Rank P = 0.72). The application of LigaSure was the best strategy for abdominal hysterectomy (Rank P = 0.54) but was not effective for laparoscopic hysterectomy (direct comparison with BVSS, MD = -31.39 [-146.61, 83.83], P = 0.59). The node-splitting models test revealed that no significant inconsistencies existed in this research. CONCLUSIONS Pituitrin application seemed to be the most effective haemostatic strategy for hysterectomy and was especially suitable for vaginal hysterectomy. The best method for reducing blood loss in abdominal hysterectomy was the application of LigaSure.