Effect of Clodronate Treatment on Risk of Fracture: A Systematic Review and Meta-analysis

A systematic review and a meta-analysis of data of literature were performed to evaluate the efficacy of clodronate in the reduction of risk of fractures in patients with osteoporosis or tumour diseases. A systematic review was conducted to identify original articles, reviews, and any other literature report suitable for the purposes of the meta-analysis, limited to prospective randomized trials that included a placebo or an untreated control arm. The search has identified 18 trials, 13 of which in patients with cancer diseases (breast cancer and multiple myeloma were prevalent), 4 in patients with osteoporosis/low BMD, and 1 in elderly women living in community. A placebo control arm was used in 13 trials. Treatment and follow-up duration ranged from 3 months to 5 years. The meta-analysis showed that treatment with clodronate was associated with a reduction of the probability of new fractures compared with controls (OR = 0.572, 95 % CI 0.465–0.704 for new vertebral fractures; OR = 0.668, 95 % CI 0.494–0.905 for new non-vertebral fractures; and OR = 0.744, 95 % CI 0.635–0.873 for new overall fractures in those articles where vertebral and non-vertebral new fractures were not considered separately). Similar findings were observed in the separate analysis in patients with cancer forms or osteoporosis. The results of the meta-analysis have demonstrated that clodronate is effective in reducing the risk of vertebral, non-vertebral, and overall fractures in patients with skeletal fragility.     

Risk Factors for Prolonged Postoperative Ileus in Colorectal Surgery: A Systematic Review and Meta-analysis

World Journal of Surgery - Prolonged postoperative ileus (PPOI) represents a frequent complication following colorectal surgery, affecting approximately 10–15% of these patients. The...     

A Systematic Review and Meta-analysis of 30-Day Outcomes Following Staged Carotid Artery Stenting and Coronary Bypass

ObjectivesTo determine the overall operative risk of cardiovascular events in patients with combined cardiac and carotid artery disease undergoing staged carotid artery stenting (CAS) and coronary artery bypass grafting (CABG).DesignSystematic review of operative risks reported in all published studies of CAS plus CABG procedures.ResultsEleven eligible, published studies were identified which reported data on 760 CAS plus CABG procedures. The majority of patients (87%) were neurologically asymptomatic and 82% had unilateral carotid stenoses. Overall mortality was 5.5% (95% confidence interval, CI: 3.4–7.6), the risk of suffering an ipsilateral stroke was 3.3% (95% CI: 1.6–5.1) and the risk of suffering ‘any’ stroke was 4.2% (95% CI: 2.4–6.1), while the 30-day risk of myocardial infarction (MI) was only 1.8% (95% CI: 0.5–3.0). However, the 30-day death and ipsilateral stroke rate was 7.5% (95% CI: 4.5–10.5) and the 30-day risk of death and any stroke was 9.1% (95% CI: 6.1–12.0), while the 30-day of death/stroke/MI was 9.4% (7.0–11.8). Cumulative risks in studies where patients underwent CABG within 48 h of CAS were not higher than in comparable studies where CABG was delayed by more than 2 weeks.ConclusionsIn a cohort of predominantly asymptomatic patients with unilateral carotid disease, the 30-day risk of death/any stroke was 9.1%. These data are comparable to previous systematic reviews evaluating the roles of staged and synchronous carotid endarterectomy (CEA) plus CABG, and suggest that staged CAS plus CABG is an attractive and less invasive alternative to CEA plus CABG. However, it remains questionable whether the observed 9% risks can be justified in any asymptomatic patient with unilateral carotid disease.     

Robotic Versus Laparoscopic Adrenalectomy: A Systematic Review and Meta-analysis

Context

Over the last decade, robot-assisted adrenalectomy has been included in the surgical armamentarium for the management of adrenal masses.

Objective

To critically analyze the available evidence of studies comparing laparoscopic and robotic adrenalectomy.

Evidence acquisition

A systematic literature review was performed in August 2013 using PubMed, Scopus, and Web of Science electronic search engines. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria.

Evidence synthesis

Nine studies were selected for the analysis including 600 patients who underwent minimally invasive adrenalectomy (277 robot assisted and 323 laparoscopic). Only one of the studies was a randomized clinical trial (RCT) but of low quality according to the Jadad scale. However, the methodological quality of included nonrandomized studies was relatively high. Body mass index was higher for the laparoscopic group (weighted mean difference [WMD]: −2.37; 95% confidence interval [CI], − 3.01 to −1.74; p < 0.00001). A transperitoneal approach was mostly used for both techniques (72.5% of robotic cases and 75.5% of laparoscopic cases; p = 0.27). There was no significant difference between the two groups in terms of conversion rate (odds ratio [OR]: 0.82; 95% CI, 0.39–1.75; p = 0.61) and operative time (WMD: 5.88; 95% CI, −6.02 to 17.79; p = 0.33). There was a significantly longer hospital stay in the conventional laparoscopic group (WMD: −0.43; 95% CI, −0.56 to −0.30; p < 0.00001), as well as a higher estimated blood loss (WMD: −18.21; 95% CI, −29.11 to −7.32; p = 0.001). There was also no statistically significant difference in terms of postoperative complication rate (OR: 0.04; 95% CI, −0.07 to −0.00; p = 0.05) between groups. Most of the postoperative complications were minor (80% for the robotic group and 68% for the conventional laparoscopic group). Limitations of the present analysis are the limited sample size and including only one low-quality RCT.

Conclusions

Robot-assisted adrenalectomy can be performed safely and effectively with operative time and conversion rates similar to laparoscopic adrenalectomy. In addition, it can provide potential advantages of a shorter hospital stay, less blood loss, and lower occurrence of postoperative complications. These findings seem to support the use of robotics for the minimally invasive surgical management of adrenal masses.     

Robotic versus Open Pancreatectomy: A Systematic Review and Meta-analysis

Background

Robotic surgery is gaining momentum with advantages for minimally invasive management of pancreatic diseases. The objective of this meta-analysis is to compare the clinical and oncologic safety and efficacy of robotic versus open pancreatectomy.

Methods

A systematic review of the literature was performed to identify studies comparing robotic pancreatectomy and open pancreatectomy. Postoperative outcomes, intraoperative outcomes, and oncologic safety were evaluated. Meta-analysis was performed using a random-effect model.

Results

Seven studies matched the selection criteria, including 137 (40 %) cases of robotic pancreatectomy and 203 (60 %) cases of open pancreatectomy. None of the included studies were randomized. Overall complication rate was significantly lower in robotic group [risk difference (RD) = ?0.12, 95 % confidence interval (CI) ?0.22 to ?0.01, P = 0.03], as well as reoperation rate (RD = ?0.12; CI ?0.2 to ?0.03, P = 0.006) and margin positivity (RD = ?0.18; 95 % CI ?0.3 to ?0.06, P = 0.003). There was no significant difference in postoperative pancreatic fistula (POPF) incidence and mortality. The median (range) conversion rate was 10 % (0–12 %).

Conclusions

The results of this meta-analysis suggest that robotic pancreatectomy is as safe and efficient as, if not superior to, open surgery for patients with benign or malignant pancreatic diseases. However, the evidence is limited and more randomized controlled trials are needed to further clearly define this role.     

Carotid Artery Stenting Versus Carotid Endarterectomy: Systematic Review and Meta-Analysis

Background  The aim of this study was to evaluate and investigate the complications of carotid endarterectomy (CEA) and carotid artery stenting (CAS) by performing a meta-analysis based on prospective randomized controlled trials (RCTs). Methods  We performed a search of multiple electronic databases for RCTs containing patients with carotid stenosis who underwent CAS or CEA, focusing on studies published during 1995–2008. Results  Eight trials with 2942 patients (1462 with CEA, 1480 with CAS) were analyzed. The pooled relative risk (RR) after CEA for stroke/death 30 days or 1 year was similar to that for CAS. Thirty-day RR = 0.69, 95% confidence interval (CI) = 0.45–1.07, p = 0.10. One-year RR = 0.88, 95% CI = 0.43–1.79, p = 0.72. The rates of death, disabling stroke, and nondisabling stroke at 30 days did not differ significantly between CEA and CAS in the subgroup analysis. Compared with CEA, the relative risk of disabling stroke/death within 30 days was not significantly less for CAS with embolic protection devices (EPDs). The relative risk of myocardial infarction within 30 days, myocardial infarction within 1 year, and cervical/peripheral nerve injury within 30 days were significantly higher after CEA; the relative risk of bradycardia/hypotension within 30 days and the 1-year restenosis rate were significantly higher after CAS. Conclusions  CAS is equal to CEA with regard to the incidence of stroke/death. These procedures may be considered complementary rather than competing modes of therapy, each of which can be optimized with careful patient selection. CAS with an EPD may be appropriate in certain patients, and in general CAS should be considered cautiously in symptomatic patients.