Fracture risk and bone mineral density levels in patients with systemic lupus erythematosus: a systematic review and meta-analysis

Previous studies suggested possible bone loss and fracture risk in patients with systemic lupus erythematosus (SLE). The aim of this systematic review and meta-analysis was to assess the strength of the relationship of SLE with fracture risk and the mean difference of bone mineral density (BMD) levels between SLE patients and controls. Literature search was undertaken in multiple indexing databases on September 26, 2015. Studies on the relationship of SLE with fracture risk and the mean difference of BMD levels between SLE patients and controls were included. Data were combined using standard methods of meta-analysis. Twenty-one studies were finally included into the meta-analysis, including 15 studies on the mean difference of BMD levels between SLE patients and controls, and 6 studies were on fracture risk associated with SLE. The meta-analysis showed that SLE patients had significantly lower BMD levels than controls in the whole body (weighted mean difference [WMD]?=??0.04; 95 % CI ?0.06 to ?0.02; P?<?0.001), femoral neck (WMD?=??0.06; 95 % CI ?0.07 to ?0.04; P?<?0.001), lumbar spine (WMD?=??0.06; 95 % CI ?0.09 to ?0.03; P?<?0.001), and total hip (WMD?=??0.05; 95 % CI ?0.06 to ?0.03; P?<?0.001). In addition, the meta-analysis also showed that SLE was significantly associated with increased fracture risk of all sites (relative risk [RR]?=?1.97, 95 % CI 1.20–3.25; P?=?0.008). Subgroup analysis by adjustment showed that SLE was significantly associated with increased fracture risk of all sites before and after adjusting for confounding factors (unadjusted RR?=?2.07, 95 % CI 1.46–2.94, P?<?0.001; adjusted RR?=?1.22, 95 % CI 1.05–1.42, P?=?0.01). Subgroup analysis by types of fracture showed that SLE was significantly associated with increased risks of hip fracture (RR?=?1.99, 95 % CI 1.55–2.57; P?<?0.001), osteoporotic fracture (RR?=?1.36, 95 % CI 1.21–1.53; P?<?0.001), and vertebral fracture (RR?=?2.97, 95 % CI 1.71–5.16; P?<?0.001). This systematic review and meta-analysis provides strong evidence for the relationship of SLE with bone loss and fracture risk.     

Computer navigation versus fluoroscopy-guided navigation for thoracic pedicle screw placement: a meta-analysis

Although application of intraoperative computer navigation technique had been integrated into placement of pedicle screws (PSs) in thoracic fusion for years, its security and practicability remain controversial. The aim of this study is to evaluate the accuracy, the operative time consumption, the amount of intraoperative blood loss, time of pedicle insertion and the incidence of complications of thoracic pedicle screw placement in patients with thoracic diseases such as scoliosis and kyphosis. Pubmed, Web of Knowledge, and Google scholar were searched to identify comparative studies of thoracic pedicle screw placement between intraoperative computer navigation and fluoroscopy-guided navigation. Outcomes of malposition rate, operative time consumption, insertion time, intraoperative blood loss, and the incidence of complications are evaluated. Fourteen articles including 1723 patients and 9019 PSs were identified matching inclusion criteria. The malposition rate was lower (RR: 0.33, 95 % CI: 0.28–0.38, P?<?0.01) in computer navigation group than that in fluoroscopy-guided navigation group; the operative time was significantly longer [weighted mean difference (WMD)?=?23.66, 95 % CI: 14.74–32.57, P?<?0.01] in computer navigation group than that in fluoroscopy-guided navigation group. The time of insertion was shorter (WMD?=??1.88, 95 % CI: ?2.25– ?1.52, P?<?0.01) in computer navigation group than that in fluoroscopy-guided navigation group. The incidence of complications was lower (RR?=?0. 23, 95 % CI: 0.12–0.46, P?<?0.01) in computer navigation group than that in the other group. The intraoperative blood loss was fewer (WMD?=??167.49, 95 % CI: ?266.39– ?68.58, P?<?0.01) in computer navigation group than that in the other. In conclusion, the meta-analysis of thoracic pedicle screw placement studies clearly demonstrated lower malposition rate, less intraoperative blood loss, and fewer complications when using computer navigation. This result provides strong evidence that computer technology could be safer and more reliable than fluoroscopy-guided navigation.     

Tubeless versus standard percutaneous nephrolithotomy: an update meta-analysis

Background

To update a previously published systematic review and meta-analysis on the efficacy and safety of tubeless percutaneous nephrolithotomy (PCNL).

Methods

A systematic literature search of EMBASE, PubMed, Web of Science, and the Cochrane Library was performed to confirm relevant studies. The scientific literature was screened in accordance with the predetermined inclusion and exclusion criteria. After quality assessment and data extraction from the eligible studies, a meta-analysis was conducted using Stata SE 12.0.

Results

Fourteen randomized controlled trials (RCTs) involving 1148 patients were included. Combined results demonstrated that tubeless PCNL was significantly associated with shorter operative time (weighted mean difference [WMD], ?3.79 min; 95% confidence interval [CI], ?6.73 to ?0.85; P = 0.012; I² = 53.8%), shorter hospital stay (WMD, ?1.27 days; 95% CI, ?1.65 to ?0.90; P < 0.001; I² = 98.7%), faster time to return to normal activity (WMD, ?4.24 days; 95% CI, ?5.76 to ?2.71; P < 0.001; I² = 97.5%), lower postoperative pain scores (WMD, ?16.55 mm; 95% CI, ?21.60 to ?11.50; P < 0.001; I² = 95.7%), less postoperative analgesia requirements (standard mean difference, ?1.09 mg; 95% CI, ?1.35 to ?0.84; P < 0.001; I² = 46.8%), and lower urine leakage (Relative risk [RR], 0.30; 95% CI 0.15 to 0.59; P = 0.001; I² = 41.2%). There were no significant differences in postoperative hemoglobin reduction (WMD, ?0.02 g/dL; 95% CI, ?0.04 to 0.01; P = 0.172; I² = 41.5%), stone-free rate (RR, 1.01; 95% CI, 0.97 to 1.05; P = 0.776; I² = 0.0%), postoperative fever rate (RR, 1.05; 95% CI, 0.57 to 1.93; P = 0.867; I² = 0.0%), or blood transfusion rate (RR, 0.79; 95% CI, 0.36 to 1.70; P = 0.538; I² = 0.0%). The results of subgroup analysis were consistent with the overall findings. The sensitivity analysis indicated that most results remained constant when total tubeless or partial tubeless or mini-PCNL studies were excluded respectively.

Conclusions

Tubeless PCNL is an available and safe option in carefully evaluated and selected patients. It is significantly associated with the advantages of shorter hospital stay, shorter time to return to normal activity, lower postoperative pain scores, less analgesia requirement, and reduced urine leakage.

     

One-port video-assisted thoracic surgery versus three-port video-assisted thoracic surgery for primary spontaneous pneumothorax: a meta-analysis

Objective

To further understand the effects of video-assisted thoracic surgery (VATS) with one-port versus three-port VATS for primary spontaneous pneumothorax (PSP).

Methods

In this study, we searched information from the PubMed, Cochrane Library, Embase, ScienceDirect, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Data databases from inception to September 2015 to collect data of randomized controlled trials (RCTs) and cohort studies about one-port VATS versus three-port VATS for PSP. Two independent authors were committed to screen literature, extract data, and assess the risk of bias of related studies. Then, we used the RevMan 5.20 software for a meta-analysis of one-port VATS versus three-port VATS for PSP.

Results

Six cohort studies involving 310 patients were finally selected in this meta-analysis. The results of our study indicate that one-port VATS had a shorter hospital stay (SMD = ?0.39, 95 % CI ?0.69 to 0.09, P = 0.01), lower VAS score of 24-h post-operative pain (SMD = ?0.78, 95 % CI ?1.40 to ?0.52, P < 0.00001), shorter chest drainage time (SMD = ?0.68, 95 % CI ?1.15 to ?0.22, P = 0.004), and lower incidence of post-operative paraesthesia (OR = 0.13, 95 % CI 0.06 to 0.29, P < 0.00001) compared with three-port VATS. However, one-port VATS had a lower patient satisfaction score at 24 h (SMD = ?0.65, 95 % CI ?0.95 to ?0.35, P < 0.0001) and 48 h (SMD = ?0.46, 95 % CI ?0.71 to ?0.21, P = 0.0002). No differences in the recurrence of pneumothorax (OR = 0.58, 95 % CI 0.20 to 1.67, P = 0.32), the operation time (SMD = 1.01, 95 % CI ?4.63 to 2.60, P = 0.58), and the satisfaction score at 72 h (SMD = ?0.11, 95 % CI ?0.44 to 0.22, P < 0.00001) were noted between the groups.

Conclusion

Current evidence suggests that one-port VATS may have certain advantages over three-port VATS for PSP. More large-scale and high-quality studies are needed for authentication.

     

Effect of daprodustat on anemia in patients with chronic kidney disease: a meta-analysis

Background

The efficacy of daprodustat for the treatment of anemic patients with chronic kidney disease (CKD) remains controversial. The aim of the study is to perform a meta-analysis of randomized controlled trials to evaluate the efficacy and safety of daprodustat for anemic patients with chronic kidney disease.

Methods

We searched Medline, Embase, Science Citation Index, Cochrane Central Register of Controlled Trials, and Clinical Trial Registries for randomized controlled trials comparing daprodustat with placebo for anemic patients with CKD.

Results

Four studies were included. Compared with placebo groups, daprodustat groups significantly increased hemoglobin (WMD 1.29 g/dL; 95% CI 0.96–1.62, p?<?0.00001), transferrin (WMD 0.67 g/dL; 95% CI 0.45–0.89, p?<?0.00001), and total iron binding capacity (WMD 9.97 g/dL; 95% CI 6.07–13.8, p?<?0.00001). Daprodustat groups significantly decreased hepcidin (WMD ??76.1 μg/L; 95% CI ??91.8 to ??60.3, p?<?0.00001) and ferritin (WMD ??63.6 μg/L; 95% CI ??96.6 to ??30.7, p?=?0.0002) compared with that of placebo groups. In addition, there was no significant difference in adverse events between the two groups.

Conclusion

Daprodustat could improve hemoglobin without increasing adverse events in the short term. Daprodustat may be another valuable choice for anemic patients with chronic kidney disease in the future.

     

Systematic review and meta-analysis of minimally invasive versus open approach for pancreaticoduodenectomy

Backgrounds and objective

The technique of minimally invasive pancreatic surgeries has evolved rapidly, including minimally invasive pancreaticoduodenectomy (MIPD). However, controversy on safety and feasibility remains when comparing the MIPD with the open pancreaticoduodenectomy (OPD); therefore, we aimed to compare MIPD and OPD with a systemic review and meta-analysis.

Methods

Multiple electronic databases were systematically searched to identify studies (up to February 2016) comparing MIPD with OPD. Intra-operative outcomes, oncologic data, postoperative complications and postoperative recovery were evaluated.

Results

Twenty-two retrospective studies including 6120 patients (1018 MIPDs and 5102 OPDs) were included. MIPD was associated with a reduction in estimated blood loss (WMD ?312.00 ml, 95 % CI ?436.30 to ?187.70 ml, p < 0.001), transfusion rate (OR 0.41, 95 % CI 0.30–0.55, p < 0.001), wound infection (OR 0.37, 95 % CI 0.20–0.66, p < 0.001) and length of hospital stay (WMD ?3.57 days, 95 % CI ?5.17 to ?1.98 days, p < 0.001). Meanwhile, MIPD group has a higher R0 resection rate (OR 1.47, 95 % CI 1.18–1.82, p < 0.001) and more lymph nodes harvest (WMD 1.74, 95 % CI 1.03–2.45, p < 0.001). However, it had longer operation time (WMD 83.91 min, 95 % CI 36.60–131.21 min, p < 0.001). There were no significant differences between the two procedures in morbidities (p = 0.86), postoperative pancreatic fistula (p = 0.17), delayed gastric empting (p = 0.65), vascular resection (p = 0.68), reoperation (p = 0.33) and mortality (p = 0.90).

Conclusions

MIPD can be a reasonable alternative to OPD with potential advantages. However, further large-volume, well-designed RCTs with extensive follow-ups are suggested to confirm and update the findings of our analysis.

     

Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis

Background

With advances in laparoscopic instrumentation and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) is technically feasible and increasingly practiced by surgeons worldwide. Traditional practice of suturing the dochotomy with T-tube drainage may be associated with T-tube-related complications. Primary duct closure (PDC) without a T-tube has been proposed as an alternative to T-tube placement (TTD) after LCBDE. The aim of this meta-analysis was to evaluate the safety and effectiveness of PDC when compared to TTD after LCBDE for choledocholithiasis.

Methods

A systematic literature search was performed using PubMed, EMBASE, MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials databases for studies comparing primary duct closure and T-tube drainage. Studies were reviewed for the primary outcome measures: overall postoperative complications, postoperative biliary-specific complications, re-interventions, and postoperative hospital stay. Secondary outcomes assessed were: operating time, median hospital expenses, and general complications.

Results

Sixteen studies comparing PDC and TTD qualified for inclusion in our meta-analysis, with a total of 1770 patients. PDC showed significantly better results when compared to TTD in terms of postoperative biliary peritonitis (OR 0.22, 95 % CI 0.06–0.76, P = 0.02), operating time (WMD, ?22.27, 95 % CI ?33.26 to ?11.28, P < 0.00001), postoperative hospital stay (WMD, ?3.22; 95 % CI ?4.52 to ?1.92, P < 0.00001), and median hospital expenses (SMD, ?1.37, 95 % CI ?1.96 to ?0.77, P < 0.00001). Postoperative hospital stay was significantly decreased in the primary duct closure with internal biliary drainage (PDC + BD) group when compared to TTD group (WMD, ?2.68; 95 % CI ?3.23 to ?2.13, P < 0.00001).

Conclusions

This comprehensive meta-analysis demonstrates that PDC after LCBDE is feasible and associated with fewer complications than TTD. Based on these results, primary duct closure may be considered as the optimal procedure for dochotomy closure after LCBDE.

     

The effect of onabotulinumtoxinA according to site of injection in patients with overactive bladder: a systematic review and meta-analysis

Purpose

This study assessed the efficacy and safety of onabotulinumtoxinA according to injection site for treatment of overactive bladder.

Methods

A systematic literature review located randomized controlled trials of onabotulinumtoxinA treatment for neurogenic detrusor overactive bladder and idiopathic overactive bladder in adults. We searched MEDLINE, EMBASE, and the Cochrane Controlled Trials Register using the Ovid platform. Meta-analysis was based on Cochrane Review Methods.

Results

Eight studies (419 participants) were included. Trigone-including injection demonstrated a significant improvement in symptom score (SMD = ? 0.53, 95% CI ? 1.04 to ? 0.02, P = 0.04, I ² = 78%), higher complete dryness rates (OR = 2.19 patients, 95% CI 1.32–3.63, P = 0.002, I ² = 41%), and lower frequency of incontinence episodes (WMD = ? 0.85 per day, 95% CI ? 1.55 to ? 0.16, P = 0.02, I ² = 87%) in patients. Comparing trigone-including injection to trigone-sparing injection, lower detrusor pressure (WMD = ? 2.55 cm H₂O, 95% CI ? 4.16 to ? 0.95, P = 0.002, I ² = 0%) and higher volume at first desire to void (WMD = 17.54 ml, 95% CI 1.00–34.07, P = 0.04, I ² = 0%) were observed with trigone-including injection. Between intradetrusor and suburothelial injection sites, there were no differences in efficacy or safety regarding the incidence of vesicoureteral reflux, hematuria, general weakness, bladder discomfort, large post-void residual, and urinary tract infection.

Conclusion

Trigone-including onabotulinumtoxinA injection has superior efficacy to trigone-sparing injection without increased complications. The depth of injection does not influence the efficacy or safety of onabotulinumtoxinA.

     

A systematic review on the efficacy and safety of PA21 versus sevelamer in dialysis patients

Aim

To evaluate the efficacy and safety of PA21 versus sevelamer in dialysis patients.

Methods

We searched Medline, Embase, Science Citation Index, Cochrane Central Register of Controlled Trials, and Clinical Trial Registries for randomized controlled trials comparing PA21 and sevelamer in dialysis patients.

Results

Four studies were included. Compared with sevelamer group, PA21 needed fewer mean daily number of tablets (WMD, ? 7.97 pill; 95% CI, ? 11.28 to ? 4.65, p < 0.00001), developed fewer all adverse events (RR = 1.05; 95% CI, 1.00 to 1.11, p = 0.05), and developed fewer gastrointestinal adverse events (RR = 1.32; 95% CI, 1.15 to 1.53, p = 0.0001). There was no significant difference in serum phosphorus between two groups (WMD, ? 0.07 mmol/L; 95% CI, ? 0.15 to 0.02, p = 0.12). As for serum calcium, there was also no significant difference between two groups (WMD, 0.27 mmol/L; 95% CI, ? 0.63 to 1.17, p = 0.55).

Conclusion

PA21 can effectively control serum phosphorus with lower pill burden and less side effects than sevelamer. PA21 might be another valuable choice for dialysis patients with hyperphosphatemia when patients are unable to tolerate sevelamer.

     

Fast-track surgery in gastrectomy for gastric cancer: a systematic review and meta-analysis

Purpose

Fast-track surgery aims to attenuate the surgical stress response, reduce complications, and shorten hospital stay. The goal of the present meta-analysis is to assess the safety and effectiveness of fast-track surgery in patients undergoing gastrectomy for gastric cancer compared with conventional perioperative care.

Methods

PubMed, Embase, the Cochrane Central Register of Controlled Trials, and reference lists of the identified studies were searched to identify randomized clinical trials that compared fast-track surgery with conventional perioperative care in patients undergoing gastrectomy for gastric cancer.

Results

Five studies with a total of 400 patients were included in the meta-analysis. Meta-analysis shows that postoperative hospital stay (weighted mean difference (WMD) ?1.87 days, 95 % confidence interval (CI), ?2.46 to ?1.28 days, P?<?0.00001), time to first passage of flatus (WMD ?0.71 days, 95 % CI, ?1.03 to ?0.39 days, P?<?0.0001), and hospital costs (WMD ?505.87 dollars, 95 % CI, ?649.91 to ?361.84 dollars, P?<?0.00001) were significantly reduced for fast-track surgery. No significant differences were found for readmission rates (relative risk (RR), 1.97 95 % CI, 0.37 to 10.64, P?=?0.43) and total postoperative complications (RR, 0.99 95 % CI, 0.56 to 1.76, P?=?0.97).

Conclusions

Fast-track surgery is safe and effective in gastrectomy for gastric cancer. Further randomized trials are needed to strengthen the conclusions.     

Predictive Value of CEA for Survival in Stage I Rectal Cancer: a Population-Based Propensity Score-Matched Analysis

Background

The aim of the study was to assess whether preoperative carcinoembryonic antigen (CEA) level is an independent predictor of overall- and cancer-specific survival in stage I rectal cancer.

Methods

Stage I rectal cancer patients were identified in the Surveillance, Epidemiology, and End Results database between 2004 and 2011. The impact of an elevated preoperative CEA level (C1-stage) compared with a normal CEA level (C0-stage) on overall and cancer-specific survival was assessed using risk-adjusted Cox proportional hazard regression models and propensity score methods.

Results

Overall, 1932 stage I rectal cancer patients were included, of which 328 (17 %) patients had C1-stage. The 5-year overall and cancer-specific survival for patients with C0-stage were 85.7 % (95 % CI 83.2–88.2 %) and 94.7 % (95 % CI 93.1–96.3 %), versus 76.8 % (95 % CI 70.9–83.1 %) and 88.1 % (95 % CI 83.3–93.2 %) for patients with C1-stage (P?<?0.001 and P?=?0.001). The negative impact of C1-stage on overall and cancer-specific survival was confirmed by risk-adjusted Cox proportional hazard regression analysis (hazard ratio [HR]?=?1.57, 95 % CI?=?1.15–2.16, P?=?0.007 and 2.04, 95 % CI?=?1.25–3.33, P?=?0.006), and after propensity score matching (overall survival [OS]: HR?=?1.46, 95 % CI?=?1.02–2.08, P?=?0.044 and cancer-specific survival [CSS]: HR?=?3.28, 95 % CI?=?1.78–6.03, P?<?0.001).

Conclusion

This is the first population-based investigation of a large cohort of exclusively stage I rectal cancer patients providing compelling evidence that elevated preoperative CEA level is a strong predictor of worse overall and cancer-specific survival.

     

Comparison of combined anterior–posterior approach versus posterior-only approach in treating adolescent idiopathic scoliosis: a meta-analysis

Purpose

Choosing a surgical approach to treat adolescent idiopathic scoliosis (AIS) is still controversial. To compare the effectiveness and safety of combined anterior–posterior approach to posterior-only approach, we conducted a meta-analysis.

Methods

We searched electronic database for relevant studies that compared anterior–posterior approach with posterior approach in AIS. Then data extraction and quality assessment were conducted. We used RevMan 5.1 for data analysis. A random effects model was used for heterogeneous data, while a fixed effect model was used for homogeneous data.

Results

A total of ten non-randomized controlled studies involving 872 patients were included. There was no significant difference in Cobb angle (95 % CI ?0.33 to 4.91, P = 0.09) and percent-predicted FEV1 (95 % CI ?6.79 to 4.54, P = 0.70) between the two groups. In subgroup analysis, the kyphosis angle correction was significantly higher than posterior group in severe subgroup (95 % CI 0.72–6.50, P = 0.01), while no significant difference was found in no-restriction subgroup (95 % CI ?2.75 to 5.42, P = 0.52). Patients in posterior group obtained a better percent-predicted FVC than those in anterior–posterior group (95 % CI ?13.18 to ?4.74, P < 0.0001). Significant less complication rate (95 % CI 2.75–17.49, P < 0.0001), blood loss (95 % CI 363.28–658.91, P < 0.00001), operative time (95 % CI 2.65–3.45, P < 0.00001) and length of hospital stay (95 % CI 1.98–22.94, P = 0.02) were found in posterior group.

Conclusions

Posterior-only approach can achieve similar coronal plane correction and percent-predicted FEV1 compared to combined anterior–posterior approach. The posterior approach even does better in sagittal correction in severe AIS patients. Significantly less complication rate, blood loss, operative time, length of hospital stay and better percent-predicted FVC are also achieved by posterior-only approach. Posterior-only approach seems to be effective and safe in treating AIS for experienced surgeons.

     

Locked plate versus retrograde intramedullary nail for periprosthetic femur fractures above total knee arthroplasty: a meta-analysis

Purpose

Locked plate (LP) and retrograde intramedullary nail (RIN) are the most commonly used treatment options for periprosthetic femur fracture above total knee arthroplasty (TKA). Controversy still exists regarding which is better. Therefore we performed a meta-analysis to compare their clinical results.

Methods

A comprehensive search was conducted through PubMed, EMBase and the Cochrane Collaboration Library. Six comparative studies (265 patients) were included for the meta-analysis.

Results

No statistically significant differences were found between the LP group and RIN group in terms of six month union rate (OR, 1.19; 95 % CI, 0.52–2.69; P?=?0.68), union time (WMD, 0.22; 95 % CI, ?0.41 to 0.84; P?=?0.50), operation time (WMD, 0.54; 95 % CI, ?13.09 to 14.17; P?=?0.94) or complication rate (OR, 0.79; 95 % CI, 0.22–2.91; P?=?0.73). The LP fixation may have a relatively higher re-operation rate (OR, 5.17; 95 % CI, 1.02–26.27; P?=?0.05) compared with RIN. The mean union time was 4.0 months in the LP group and 3.7 months in the RIN group.

Conclusion

This meta-analysis found no statistically significant difference in six month union rate, union time, operation time and complication rate between the LP group and RIN group. The RIN fixation may have a potential of lower re-operation rate compared with LP. The mean union time was 4.0 months in the LP group and 3.7 months in the RIN group.

     

Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis

Background

Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery.

Methods

We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria.

Results

In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD ??2.37 days; 95% CI ??3.00 to ??1.73; P 0.000) and earlier time to first flatus (WMD ??0.63 days; 95% CI ??0.90 to ??0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51–0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI ??918.15 to ??684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52–1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53–3.34; P 0.549) were found between the two groups.

Conclusions

ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.

     

Interspinous spacers versus posterior lumbar interbody fusion for degenerative lumbar spinal diseases: a meta-analysis of prospective studies

Purpose

Our aim is to evaluate the safety and effectiveness of interspinous spacers versus posterior lumbar interbody fusion (PLIF) for degenerative lumbar spinal diseases.

Methods

A comprehensive literature search was performed using PubMed, Web of Science and Cochrane Library through September 2015. Included studies were performed according to eligibility criteria. Data of complication rate, post-operative back visual analogue scale (VAS) score, Oswestry Disability Index (ODI) score, estimated blood loss (EBL), operative time, length of hospital stay (LOS), range of motion (ROM) at the surgical, proximal and distal segments were extracted and analyzed.

Results

Ten studies were selected from 177 citations. The pooled data demonstrated the interspinous spacers group had a lower estimated blood loss (weighted mean difference [WMD]: ?175.66 ml; 95 % confidence interval [CI], ?241.03 to ?110.30; p?<?0.00001), shorter operative time (WMD: ?55.47 min; 95%CI, ?74.29 to ?36.65; p?<?0.00001), larger range of motion (ROM) at the surgical segment (WMD: 3.97 degree; 95%CI, ?3.24 to ?1.91; p?<?0.00001) and more limited ROM at the proximal segment (WMD: ?2.58 degree; 95%CI, 2.48 to 5.47; p?<?0.00001) after operation. Post-operative back VAS score, ODI score, length of hospital stay, complication rate and ROM at the distal segment showed no difference between the two groups.

Conclusions

Our meta-analysis suggested that interspinous spacers appear to be a safe and effective alternative to PLIF for selective patients with degenerative lumbar spinal diseases. However, more randomized controlled trials (RCT) are still needed to further confirm our results.

     

Sevoflurane preconditioning in on-pump coronary artery bypass grafting: a meta-analysis of randomized controlled trials

Purpose

Sevoflurane preconditioning (SevoPreC) has been proved to prevent organ ischemia/reperfusion (I/R) injury in various animal models and preclinical studies. Clinical trials on cardioprotection by SevoPreC for adult patients undergoing coronary artery bypass graft (CABG) revealed mixed results. The aim of this meta-analysis was to evaluate the cardiac effect of SevoPreC in on-pump CABG.

Methods

Randomized controlled trials (RCT) comparing the cardiac effect of SevoPreC (compared with control) in adult patients undergoing CABG were searched from PubMed, Embase, and the Cochrane Library (up to November 2015). The primary endpoints were postoperative troponin levels. Additional endpoints were CK-MB levels, mechanic ventilation (MV) duration, intensive care unit (ICU) stay, and hospital length of stay (LOS).

Results

Six trials with eight comparisons enrolling a total of 384 study patients reporting postoperative troponin levels were identified. Compared with controls, SevoPreC decreased postoperative myocardial troponin levels [standardized mean difference (SMD) = ?0.38; 95 % CI, ?0.74 to ?0.03; P = 0.04; I ² = 63.9 %]. However, no significant differences were observed in postoperative CK-MB levels [weighted mean difference (WMD) = ?1.71; P = 0.37; I ² = 37.7 %], MV duration (WMD = ?0.53; P = 0.47; I ² = 0.0 %), ICU stay (WMD = ?0.91; P = 0.39; I ² = 0.9 %), and hospital LOS (WMD = 0.08; P = 0.86; I ² = 8.0 %).

Conclusion

Available evidence from the present systematic review and meta-analysis suggests that sevoflurane preconditioning may reduce troponin levels in on-pump CABG. Future high-quality, large-scale clinical trials should focus on the early and long-term clinical effect of SevoPreC in on-pump CABG.

     

Balloon kyphoplasty versus percutaneous vertebroplasty for treatment of osteoporotic vertebral compression fractures (OVCFs)

Summary

The study investigated whether kyphoplasty (KP) was superior to vertebroplasty (VP) in treating patients with osteoporotic vertebral compression fractures (OVCFs). KP may be superior to VP for treating patients with OVCFs based on long-term VAS and ODI but not short-term VAS. Further large-scale trials are needed to verify these findings due to potential risk of selection bias.

Introduction

This study aimed to assess whether KP was superior to VP in treating patients with OVCFs.

Methods

The Medline, Embase, and Cochrane databases and references within articles and proceedings of major meetings were systematically searched. Eligible studies included patients with OVCFs who received either KP or VP. Standard mean differences (SMDs) and relative risks (RRs) were used as measures of efficacy and safety in a random-effects model.

Results

Eleven studies enrolling 869 patients with OVCFs were identified as eligible for final analysis. Compared with VP, KP was associated with significant improvements in long-term (SMD, ?0.70; 95 % confidence interval [CI]: ?1.30, ?0.10; P?=?0.023) visual analog scale (VAS); short-term (SMD, ?1.50; 95 % CI: ?2.94, ?0.07; P?=?0.040) and long-term (SMD, ?1.03; 95 % CI: ?1.88, ?0.18; P?=?0.017) Oswestry Disability Indexes (ODIs); short-term (SMD, ?0.74; 95 % CI: ?1.42, ?0.06; P?=?0.032) and long-term (SMD, ?0.71; 95 % CI: ?1.19, ?0.23; P?=?0.004) kyphosis angles; and vertebral body height (SMD, 1.56; 95 % CI: 0.62, 2.49; P?=?0.001) and anterior vertebral body height (SMD, 3.04; 95 % CI: 0.53, 5.56; P?=?0.018). KP was also associated with a significantly longer operation time (SMD, 0.73; 95 % CI: 0.26, 1.19; P?=?0.002) and a lower risk of cement extravasation (RR, 0.68; 95 % CI: 0.48, 0.96; P?=?0.030) compared with VP. No significant differences were found in the short-term VAS, posterior vertebral body height, and adjacent-level fractures.

Conclusion

Acknowledging some risk of selection bias, KP displayed a significantly better performance compared with VP only in one of the two primary endpoints, that is, for ODI but not for short-term VAS. Further randomized studies are required to confirm these results.

     

Stroke increases the risk of hip fracture: a systematic review and meta-analysis

Many studies have investigated the association between stroke and hip fracture risk, but the precise association was still unclear due to insufficient statistical power in single studies with relatively small sample size. Thus, we firstly conducted a meta-analysis of all published studies to precisely estimate the relationship of stroke with hip fracture risk. The strength for this relationship was weighed by pooled relative risks (RRs) with 95 % confidence intervals (95 % CIs) after adjustment for confounding variables. Stratified analyses by study design and ethnicity and sensitivity analysis were also performed. Two investigators independently performed a comprehensive literature search in databases of PubMed, Embase, and Wanfang for eligible articles. A Bayesian meta-analysis was also performed to get a more precise assessment of the relationship. Eleven relevant studies from 10 publications were finally included into our meta-analysis according to the inclusion criteria. Overall, stroke significantly and independently increased the risk of hip fracture (RR?=?2.06, 95 % CI 1.68–2.52, P?<?0.001). Bayesian meta-analysis showed that stroke was also associated with an over two-fold increased risk of hip fracture (RR?=?2.11, 95 % CI 1.62–2.75). In stratified analysis, stroke could increase the risk of hip fracture in Caucasians (RR?=?2.36, 95 % CI 1.83–3.05, P?<?0.001). These data support the notion that stroke is an independent risk factor for hip fracture, and patients with stroke have a two-fold increased risk of hip fracture than those without stroke.     

Predictors for persistent urodynamic stress incontinence following extensive pelvic reconstructive surgery with and without midurethral sling

Introduction and hypothesis

The objective of this study was to identify the predictors for persistent urodynamic stress incontinence (P-USI) in women following extensive pelvic reconstructive surgery (PRS) with and without midurethral sling (MUS).

Mmethods

A total of 1,017 women who underwent pelvic organ prolapse (POP) surgery from January 2005 to December 2013 in our institutions were analyzed. We included 349 USI women who had extensive PRS for POP stage III or more of whom 209 underwent concomitant MUS.

Results

Of the women who underwent extensive PRS without MUS, 64.3 % (90/140) developed P-USI compared to only 10.5 % (22/209) of those who had concomitant MUS. Those with concomitant MUS and PRS alone were at higher risk of developing P-USI if they had overt USI [odds ratio (OR) 2.2, 95 % confidence interval (CI) 1.3–4.0, p?=?0.014 and OR 4.7, 95 % CI 2.0–11.3, p?<?0.001, respectively], maximum urethral closure pressure (MUCP) of?<?60 cm H₂O (OR 5.0, 95 % CI 3.0–8.1, p?<?0.001 and OR 5.3, 95 % CI 2.7–10.4, p?<?0.001, respectively), and functional urethral length (FUL) of?<?2 cm (OR 5.4, 95 % CI 2.7–8.8, p?<?0.001 and OR 3.9, 95 % CI 2.4–6.9, p?<?0.001, respectively). Parity?≥?6 (OR 3.9, 95 % CI 1.7–5.2, p?<?0.001) and Prolift T (OR 3.1, 95 % CI 1.9–4, p?<?0.001) posed a higher risk of P-USI in those with concomitant surgery. Perigee and Avaulta A seemed to be protective against P-USI in those without MUS.

Conclusions

Overt USI with advanced POP together with low MUCP and FUL values have a higher risk of developing P-USI. Therefore, counseling these women is worthwhile while considering the type of mesh used.

     

Meta-analysis of epidural analgesia versus peripheral nerve blockade after total knee joint replacement

Background

Postoperative pain after major knee surgery can be severe. Our aim was to compare the outcomes of epidural analgesia and peripheral nerve blockade (PNB) in patients undergoing total knee joint replacement (TKR). Moreover, we aimed to compare outcomes of adductor canal block (ACB) with those of femoral nerve block (FNB) after TKR.

Methods

We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; and the Cochrane Central Register of Controlled Trials (CENTRAL). We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above databases. Pain intensity assessed on visual analogue scale (VAS), nausea and vomiting, systolic hypotension, and urinary retention was the reported outcome parameters.

Results

We identified 12 randomised controlled trials (RCTs) comparing outcomes of epidural analgesia and PNB reporting a total of 670 patients. There was no significant difference between two groups in VAS scores at 0–12 h (MD ?0.48; 95 % CI ?1.07–0.11, P = 0.11), 12–24 h (MD 0.04; 95 % CI ?0.81–0.88, P = 0.93), and 24–48 h (MD 0.16; 95 % CI ?0.08–0.40, P = 0.19). However, epidural analgesia was associated with significantly higher risk of postoperative nausea and vomiting (RR 1.65; 95 % CI, 1.20–2.28, P = 0.002), hypotension (RR 1.76; 95 % CI, 1.26–2.45, P = 0.0009), and urinary retention (RR 4.51; 95 % CI, 2.27–8.96, P < 0.0001) compared to PNB. Moreover, pooled analysis of data from 6 RCTs demonstrated no significant difference in VAS score between ACB and FNB at 24 h (MD ?0.00; 95 % CI, ?0.56–0.56, P = 0.99) and 48 h (MD ?0.06; 95 % CI, ?0.14–0.03, P = 0.23).

Conclusions

PNB is as effective as epidural analgesia for postoperative pain management in patients undergoing TKR. Moreover, it is associated with significantly lower postoperative complications. ACB appears to be an effective PNB with similar analgesic effect to FNB after TKR. Future RCTs may provide better evidence regarding knee range of motion, length of hospital stay, and neurological complications.