How to perform a systematic review

Through the identification, critical appraisal and summary of evidence, systematic reviews play a pivotal role in making sense of the underlying evidence on which to base healthcare decisions. In this article we outline how to perform a Cochrane review, namely a systematic review produced with the support of the Cochrane Collaboration and published in The Cochrane Library. As well as describing the basic principles and methodology of doing a Cochrane review, we identify some of the challenges involved and highlight some issues of more specific relevance to reviews in anaesthesia.     

An Analysis of Complication Risk Factors in 641 Nipple Reconstructions

Nipple‐areola reconstruction represents the completion of the breast restorative process and is associated with significant positive psychological implications. While factors such as medical comorbidities, smoking status, and radiation therapy have been shown to be associated with an increase in complications following breast reconstruction, their impact on nipple reconstruction remains largely unaddressed in the literature. An IRB‐approved, retrospective review of 472 patients who underwent nipple reconstruction at Wake Forest University over a 15‐year period was completed. Demographic and surgical characteristics were assessed including age, body mass index, medical comorbidities, smoking status, need for radiation, breast reconstruction type, and nipple flap used. Four hundred and seventy‐two patients with 641 nipple reconstructions were included with an average follow‐up of 56.5 months. Radiation prior to nipple reconstruction was required in 146 breasts (22.8%). Overall, postoperative nipple projection problems occurred in 7.6% of reconstructions with a 4.1% rate of other complications, including nipple necrosis, tip loss, wound infection and wound breakdown. Implant‐based reconstruction and radiation were associated with significantly more nipple projection problems (p = 0.009 and 0.05, respectively). Higher rates of complications and nipple projection problems were seen with skate flap reconstruction compared to a star flap (p = 0.046 and 0.001, respectively). Implant‐based breast reconstruction and radiotherapy are associated with higher rates of nipple reconstruction problems. Identification of patient and surgical variables associated with increased risk of poor outcomes preoperatively could help in patient counseling and selection of the most appropriate method of breast and nipple reconstruction.     

Influence of diabetes mellitus on postoperative complications and failure in head and neck free flap reconstruction: A systematic review and meta‐analysis

We performed a systematic review and meta‐analysis to determine whether diabetic patients have an increased rate of postoperative complications compared to nondiabetic patients after head and neck free flap reconstruction. A systematic review of PubMed Database between 1966 and 2012 was performed. RevMan 5.0 was used for meta‐analysis. A retrospective medical chart review of 7890 patients to identify those who had a failed microsurgical reconstruction of the head and neck region at Chang Gung Memorial Hospital was also carried out. The result revealed that patients with diabetes mellitus have a 1.76 increased risk of complications (odds ratio [OR] = 1.76; 95% confidence interval [CI] = 1.11–2.79) with minimal heterogeneity (I ² = 22%; p = .28). The prevalence of diabetes mellitus in patients with failed free flaps for head and neck reconstruction is 15%. The incidence of diabetes mellitus in these patients with failed free flaps is 2.3 times higher than in the general population.<copy;2013> © 2014 Wiley Periodicals, Inc. Head Neck 37 : 615–618, 2015     

Importance of the suprasternal notch to nipple distance (SSN:N) for vascular complications of the nipple areola complex (NAC) in the superior pedicle vertical mammaplasty: A retrospective analysis

Background

The superior pedicle, frequently used with vertical mammaplasty, bears some risk for vascular complications of the nipple areola complex (NAC) particularly in large breasts. The suprasternal notch to nipple distance (SSN:N), geometrically associated with the longitudinal axis of the breast and length of the superior pedicle, might be an indicative parameter to assess these complications. Importance of the SSN:N for vascular complication of the NAC was focussed upon in this study.

Material and methods

Arterial and venous complications of 104 patients following the superior pedicle vertical mammaplasty were retrospectively evaluated both sided (n = 208 breasts), according to the preoperatively measured SSN:N. Binary logistic regression (p ≤ 0.05) was used for statistical evaluation.

Results

Probability of vascular compromise of the NAC is influenced by the SSN:N within the context of the superior pedicle vertical mammaplasty. An SSN:N > 30 cm (n = 112 breasts) is subject to venous (p = 0.002) as well as arterial (p = 0.232) complications of the NAC, both of which may result in partial necrosis of the tissue (p = 0.029).

Conclusion

The SSN:N measurement can be helpful to identify patients at risk for vascular complications of the superiorly stalked NAC. Modifications of the superior pedicle or other pedicles potentially providing enhanced vascular impact might be considered with an SSN:N beyond 30 cm to reduce vasculature-related complications of the NAC.     

乳晕放射状切开松解合并双环形荷包缝合治疗乳头内陷

目的：介绍一种有效治疗乳头内陷的手术方法。方法：采用乳晕放射状切口切开乳晕皮肤,离断松解短缩的纤维结缔组织及平滑肌,松解后应用双环形荷包缝合形成乳头颈部和根部并防止回缩。结果：应用该方法矫正治疗乳头内陷11例,术后回访1～6个月,其中10例效果良好,1例一侧乳头重新回缩。结论：乳晕放射状切开松解合并双环形荷包缝合法对于矫正乳头内陷是一种良好的手术方法,对Ⅰ型和Ⅱ型乳头内陷有其良好的应用效果。     

Post-colonoscopy appendicitis: A case report and systematic review

Colonoscopy is a widely used diagnostic and therapeutic modality with a relatively low morbidity.However,given the large volume of procedures performed,awareness of the infrequent complications is essential.Perforation is an established complication of colonoscopy,and can range from 0.2%-3%depending on the series,population and modality of colonoscopy.Acute appendicitis after colonoscopy is an extremely rare event,and a cause-effect relationship between the colonoscopy and the appendicitis is not well documented.In addition,awareness of this condition can aid in prompt diagnosis.Relatively mild symptoms and exclusion of bowel perforation by contrast studies do not exclude appendicitis from the differential diagnosis for post-colonoscopy pain.In addition to the difficult diagnosis inherent to postcolonoscopy appendicitis,treatment strategies have varied greatly.This paper reviews these approaches.We also expand upon prior articles by giving guidance for the role of nonoperative management in these patients.This case and review of the literature will help to create awareness about this complication,and guide optimal treatment of pericolonoscopy appendicitis.     

双新月形乳晕瓣结合乳腺组织瓣矫治重度乳头内陷

目的：探索一种效果持久且美容效果良好的矫治重度乳头内陷的方法。方法：彻底松解乳头下引起乳头内陷的纤维束和部分缩短的乳腺导管,移植乳腺组织瓣填充乳头下的空隙。设计上下两个新月形乳晕瓣旋转缝合至乳头颈部,增加乳头颈高度并使乳头挺立、饱满。结果：2001年3月至2008年5月共矫治43例72侧重度乳头内陷患者,经随访6个月～2年,效果持久,无一例复发,远期乳头感觉及勃起功能正常,乳头外形良好,切口痕迹不显。结论：双新月形乳晕瓣加强乳头颈部结合乳腺组织瓣填充原乳头下空隙是矫治重度乳头内陷的较为理想的方法,值得临床推广。     

Developing evidence-based standards for diagnosis and management of lower urinary tract or pelvic floor dysfunction

The International Continence Society (ICS) has a key role in standardizing terminology related to lower urinary tract and pelvic organ dysfunction. The ICS Standardization Steering Committee (SSC) presents the new structure and process by which future ICS Standards will be developed. The new processes aim to meet present-day evidence-based practice requirements, and to foster unbiased, inclusive, and transparent development. For each new ICS Standard, the SSC will oversee a dedicated ad hoc Working Group (WG). Applications to chair or contribute to a WG will be invited from the ICS membership. The SSC will select the Chairperson, and work with him or her to select the WG composition, balanced to represent key disciplines, stakeholders, and regions. Consultants can be invited to contribute to the WG where specific need arises. Every WG will review current knowledge, adhering to evidence-based medicine requirements. Progress reports will be reviewed by the SSC, and amendments recommended, culminating in a first draft. The draft will be offered to the ICS membership and additional relevant experts for comment. Further revision, if needed, will result in a document, which the SSC will submit to the ICS Trustees, as arbiters of whether the document should be adopted as an ICS Standard. The SCC will then coordinate with the WG to ensure that the new ICS Standard is published and disseminated. Implementation strategies, such as education, audit, accreditation, and research initiatives will be linked to the Standards where appropriate. Revisions of ICS Standards will be undertaken to maintain contemporaneous relevance.     

A systematic review and meta-analysis on the effect of neoadjuvant chemotherapy on complications following immediate breast reconstruction

BackgroundThe impact of neoadjuvant chemotherapy (NACT) on surgical outcomes following immediate breast reconstruction (IBR) remains unclear. While it is generally considered safe practice to perform an IBR post NACT, reported complication rates in published data are highly variable with the majority of studies including fewer than 50 patients in the NACT and IBR arm. To evaluate this further, we conducted a systematic review and meta-analysis on the effect of NACT on autologous and implant based immediate breast reconstructions. We aimed to assess for differences in the post-operative course following IBR between patients who received NACT with those who did not.MethodsPubMed, EMBASE, and Cochrane Library were searched from 1995 to Sept 2, 2020 to identify articles that assessed the impact of NACT on IBR. All included studies assessed outcomes following IBR. Only studies comparing reconstructed patients receiving NACT to a control group of women who did not receive NACT were included. Unadjusted relative risk of outcomes between patients who received or did not receive NACT were synthesized using a fixed-effect meta-analysis. The evidence was assessed using the Newcastle Ottawa Scale scores and GRADE. Primary effect measures were risk ratios (RRs) with 95% confidence intervals.ResultsA total 17 studies comprising 3249 patients were included in the meta-analyses. Overall, NACT did not increase the risk of complications after immediate breast reconstructions (risk ratio [RR]: 0.91, 95% CI 0.74 to 1.11, p = 0.34). There was a moderate, but not significant, increase in flap loss following NACT compared with controls (RR: 1.23, 95% CI 0.70 to 2.18, p = 0.47; I² = 0%). Most notably, there was a statistically significant increase in implant/expander loss after NACT (RR: 1.54, 95% CI 1.04 to 2.29, p = 0.03; I² = 34%). NACT was not shown to significantly increase the incidence of hematomas, seromas or wound complications, or result in a significant delay to commencing adjuvant therapy (RR: 1.59, 95% CI 0.66 to 3.87, p = 0.30).ConclusionImmediate breast reconstruction after NACT is a safe procedure with an acceptable post-operative complication profile. It may result in a slight increase in implant loss rates, but it does not delay commencing adjuvant therapy.     

A systematic review of outcomes of abdominoplasty

Abstract

Abdominoplasty is a well-established operation to remove abdominal tissue excess. The patients' benefits and risks of this surgical treatment are, however, incompletely studied. The aim of this study was to evaluate the quality of evidence of benefits and risks for patients having abdominoplasty from massive weight loss or childbirth. Outcome measures were quality-of-life, respiratory function, back pain, and complication rates. PubMed, Cochrane Database of Systematic Reviews, CRD, CINDAHL, AMED, PsycInfo and different Health technology Assessment organizations (SBU, Kunnskapssenteret, Sundhetsstyrelsen) were searched for articles published until October 2011. Inclusion criteria were studies written in English or Scandinavian language including at least 30 patients with a control group and a case series of at least 100 patients. Review articles and case studies were excluded. The scientific level of evidence was evaluated using the GRADE-system. One small controlled study on abdominoplasty was found indicating a positive effect on quality-of-life. No controlled studies evaluating the other outcomes respiratory function and back pain were found. One prospective study reported minor complications averaging to 25%. Fourteen retrospective studies reported the same pattern. The major complication venous thromboembolism was found in 2%–8% in three series. It is concluded that the quality of evidence of positive health effects for patients having abdominoplasty is very low concerning all studied outcomes.     

重视循证研究进展 规范胃癌综合治疗

循证医学是临床医学的新模式,正不断改变着临床医师的理念和实践。虽然针对胃癌治疗的临床研究已很深入,并发挥了重要的作用,但是其结论并不相同,也各有其局限性。临床医师在治疗胃癌病人过程中,应合理运用循证依据,并结合病人自身情况,制定个体化治疗方案。     

在普通外科诊疗实践中正确掌握和合理运用循证医学原则

普通外科逐步进入循证医学时代。但目前外科领域的循证医学研究数量少,质量不高。外科医生应重视循证医学研究,更现实的是利用好现有的循证医学资料。在此过程中,应对循证医学资料仔细分析,并在临床实践中合理运用,即在适当的时候,适合的病人中应用循证医学原则。     

Civiale,stones and statistics: the dawn of evidence‐based medicine

The statistical research on bladder stones conducted by Paris urologist Jean Civiale in the early 19th century provided historical roots for evidence‐based medicine. Translations of original documents by Civiale describing his work on treating bladder stones, and the discussion by members of the Paris Academy of Sciences that commented on his results in 1835, were reviewed. By collecting statistical data on a wide scale throughout Europe, Civiale argued that his new transurethral procedure, called lithotripsy, was superior to the more widely used but highly morbid technique, lithotomy. The Paris Academy of Sciences commented on his research and chose the occasion to debate whether or not numerical reasoning and statistics had any place in medical and surgical practice. Civiale’s insights and methods espoused similar concepts and ideas driving today’s new paradigm of evidence‐based medicine.     

Intracytoplasmic sperm injection: a review of risks and complications

In the mini‐review section this month, there are four reviews on different subjects: intracytoplasmic sperm injection, photodynamic therapy in prostate cancer, and the roles of re‐TUR and intravesical chemotherapy in superficial bladder cancer. There is a fifth paper in the section which is not a mini‐review, but rather a short appreciation of Terence Millin, a pioneer in urological surgery, and a great surgical innovator.