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Role of immune checkpoint inhibitor-based therapies for metastatic renal cell carcinoma in the first-line setting: A Bayesian network analysis. EBioMedicine 2019; 47:78-88. [PMID: 31439476 PMCID: PMC6796578 DOI: 10.1016/j.ebiom.2019.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 07/23/2019] [Accepted: 08/02/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Several novel immune checkpoint inhibitor (ICI)-based treatments exhibited promising survival benefits for metastatic renal cell carcinoma (mRCC), yet there is no current guidance regarding the optimum first-line regimen. We performed this network analysis to compare the efficacy and safety of all available treatments for mRCC. METHODS A systematic search of literature was conducted up to April 30, 2019, and the analysis was done on a Bayesian fixed-effect model. FINDINGS Twenty-five randomized clinical trials (RCTs) involving 13,010 patients were included in this study. The results showed that for overall survival, pembrolizumab plus axitinib (hazard ratio [HR]: 0.53; 95% credible interval [CrI]: 0.38-0.73) and nivolumab plus ipilimumab (HR: 0.63; 95% CrI: 0.50-0.79) were significantly more effective than sunitinib, and pembrolizumab plus axitinib was probably (68%) to be the best choice. For progression-free survival, cabozantinib (HR: 0.66; 95% CrI: 0.46-0.94), pembrolizumab plus axitinib (HR: 0.69; 95% CrI: 0.57-0.84), avelumab plus axitinib (HR: 0.69; 95% CrI: 0.56-0.85), nivolumab plus ipilimumab (HR: 0.82; 95% CrI: 0.68-0.99), and atezolizumab plus bevacizumab (HR: 0.86; 95% CrI: 0.74-0.99) were statistically superior to sunitinib, and cabozantinib was likely (43%) to be the preferred options. Nivolumab plus ipilimumab (OR: 0.50; 95% CrI: 0.28-0.84), and atezolizumab plus bevacizumab (OR: 0.56; 95% CrI: 0.36-0.83) were associated with significantly lower rate of high-grade adverse events than sunitinib. INTERPRETATION Our findings demonstrate that pembrolizumab plus axitinib might be the best treatment for mRCC, while nivolumab plus ipilimumab has the most favorable balance between efficacy and acceptability, and may provide new guidance to make treatment decisions. FUND: This research was supported by the Henan Provincial Scientific and Technological Research Project (Grant No. 192102310036).
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Sultan AM, Shehta A, Salah T, Elshoubary M, Fathy O, Wahab MA. Response to: Effective and Safe Living Donor Hepatectomy Under Intermittent Inflow Occlusion and Outflow Pressure Control. J Gastrointest Surg 2019; 23:1290-1291. [PMID: 30887294 DOI: 10.1007/s11605-019-04191-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 02/26/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Ahmad Mohamed Sultan
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Ahmed Shehta
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt.
| | - Tarek Salah
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Elshoubary
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Omar Fathy
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Abdel Wahab
- Department of Surgery, Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
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Radiofrequency-assisted liver resection: Technique and results. Surg Oncol 2018; 27:415-420. [PMID: 30217296 DOI: 10.1016/j.suronc.2018.05.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 05/13/2018] [Accepted: 05/26/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Radiofrequency (RF)-assisted liver resection allows non-anatomical liver resection with reduced blood loss and offers the opportunity for a combination of resection and ablation. However, there are still concerns with regard to postoperative complications related to this technique. In the present study, we discuss the technical aspects of RF-assisted liver resections and analyse the rate of perioperative complications, focusing on post-hepatectomy liver failure (PLF), bile leak and abscess, and mortality. METHODS Between 2001 and 2015, 857 consecutive open and laparoscopic elective RF-assisted liver resections for benign and malignant liver tumours were reviewed retrospectively to assess perioperative outcomes. RESULTS Median intraoperative blood loss was 130 mL, with 9.8% of patients requiring blood transfusion. Intra-abdominal collections requiring percutaneous drainage developed in 8.7% of all patients, while bile leak at resection margin developed in 2.8% of the cases. Major liver resection was performed in 34% of patients and the incidence of PLF was 1.5% with one directly related mortality (0.1%). CONCLUSION RF-assisted liver resection has evolved into a feasible and safe technique of liver resection with an acceptable incidence of perioperative morbidity and a low incidence of PLF and related mortality.
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El Shobary M, Salah T, El Nakeeb A, Sultan AM, Elghawalby A, Fathy O, Wahab MA, Yassen A, Elmorshedy M, Elkashef WF, Shiha U, Elsadany M. Spray Diathermy Versus Harmonic Scalpel Technique for Hepatic Parenchymal Transection of Living Donor. J Gastrointest Surg 2017; 21:321-329. [PMID: 27798785 DOI: 10.1007/s11605-016-3312-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/13/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Liver parenchymal transection is the most invasive and challenging part in the living donor operation. The study was planned to compare the safety, efficacy, and outcome of harmonic scalpel versus spray diathermy as a method of parenchymal liver transection in donor hepatectomy. PATIENT AND METHOD Eighty consecutive patients, who were treated by living donor liver transplantation (LDLT), were included in the study. The study population was divided into two groups according to the method of liver transection: group A by harmonic scalpel (HS) and group B by spray diathermy (SD). The primary outcome was the volume of blood loss during transection. Secondary outcomes were time of transection, number of ligatures needed during transection, pathological changes at cut surface, postoperative morbidities, cost, and hospital stay RESULTS: Blood loss during overall liver transection and in each zone was significantly less in the SD than in the HS group (P = 0.015). The number of ligatures was significantly less in the SD than in the HS group (P = 0.0001). The SD group had significantly higher level of serum bilirubin, serum glutamic pyruvic transaminase (SGPT), and international normalized ratio (INR) levels on postoperative day 3 than the HS group. Lateral tissue coagulation and hepatic necrosis are significantly less in HS group. The overall incidence of postoperative morbidities was the same in both groups. The cost was higher in HS group than SD group (US$760 vs. US$40 P = 0.0001). CONCLUSION Spray diathermy is an effective method of parenchymal transection with significantly lower blood loss and lower cost compared to HS with no increase in morbidity. HS is associated with earlier recovery of liver functions.
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Affiliation(s)
- Mohamed El Shobary
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Tarek Salah
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Ayman El Nakeeb
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt.
| | - Ahmad M Sultan
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Ahmed Elghawalby
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Omar Fathy
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Mohamed Abdel Wahab
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Amro Yassen
- Anesthesia and Intensive Care Department, Mansoura Faculty of Medicine, Mansoura University, Daqahlia, Egypt
| | - Mohamed Elmorshedy
- Anesthesia and Intensive Care Department, Mansoura Faculty of Medicine, Mansoura University, Daqahlia, Egypt
| | - Wagdi F Elkashef
- Pathology Department, Mansoura Faculty of Medicine, Mansoura University, Daqahlia, Egypt
| | - Usama Shiha
- Radiology Department, Gastroenterology Surgical Center, Mansoura University, Daqahlia, Egypt
| | - Mohamed Elsadany
- Internal Medicine Department, Mansoura Faculty of Medicine, Mansoura University, Daqahlia, Egypt
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Moggia E, Rouse B, Simillis C, Li T, Vaughan J, Davidson BR, Gurusamy KS. Methods to decrease blood loss during liver resection: a network meta-analysis. Cochrane Database Syst Rev 2016; 10:CD010683. [PMID: 27797116 PMCID: PMC6472530 DOI: 10.1002/14651858.cd010683.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Liver resection is a major surgery with significant mortality and morbidity. Specialists have tested various methods in attempts to limit blood loss, transfusion requirements, and morbidity during elective liver resection. These methods include different approaches (anterior versus conventional approach), use of autologous blood donation, cardiopulmonary interventions such as hypoventilation, low central venous pressure, different methods of parenchymal transection, different methods of management of the raw surface of the liver, different methods of vascular occlusion, and different pharmacological interventions. A surgeon typically uses only one of the methods from each of these seven categories. The optimal method to decrease blood loss and transfusion requirements in people undergoing liver resection is unknown. OBJECTIVES To assess the effects of different interventions for decreasing blood loss and blood transfusion requirements during elective liver resection. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Science Citation Index Expanded to September 2015 to identify randomised clinical trials. We also searched trial registers and handsearched the references lists of identified trials. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different methods of decreasing blood loss and blood transfusion requirements in people undergoing liver resection. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and collected data. We assessed the risk of bias using Cochrane domains. We conducted a Bayesian network meta-analysis using the Markov chain Monte Carlo method in WinBUGS 1.4, following the guidelines of the National Institute for Health and Care Excellence Decision Support Unit guidance documents. We calculated the odds ratios (OR) with 95% credible intervals (CrI) for the binary outcomes, mean differences (MD) with 95% CrI for continuous outcomes, and rate ratios with 95% CrI for count outcomes, using a fixed-effect model or random-effects model according to model-fit. We assessed the evidence with GRADE. MAIN RESULTS We identified 67 randomised clinical trials involving a total of 6197 participants. All the trials were at high risk of bias. A total of 5771 participants from 64 trials provided data for one or more outcomes included in this review. There was no evidence of differences in most of the comparisons, and where there was, these differences were in single trials, mostly of small sample size. We summarise only the evidence that was available in more than one trial below. Of the primary outcomes, the only one with evidence of a difference from more than one trial under the pair-wise comparison was in the number of adverse events (complications), which was higher with radiofrequency dissecting sealer than with the clamp-crush method (rate ratio 1.85, 95% CrI 1.07 to 3.26; 250 participants; 3 studies; very low-quality evidence). Among the secondary outcomes, the only differences we found from more than one trial under the pair-wise comparison were the following: blood transfusion (proportion) was higher in the low central venous pressure group than in the acute normovolemic haemodilution plus low central venous pressure group (OR 3.19, 95% CrI 1.56 to 6.95; 208 participants; 2 studies; low-quality evidence); blood transfusion quantity (red blood cells) was lower in the fibrin sealant group than in the control (MD -0.53 units, 95% CrI -1.00 to -0.07; 122 participants; 2; very low-quality evidence); blood transfusion quantity (fresh frozen plasma) was higher in the oxidised cellulose group than in the fibrin sealant group (MD 0.53 units, 95% CrI 0.36 to 0.71; 80 participants; 2 studies; very low-quality evidence); blood loss (MD -0.34 L, 95% CrI -0.46 to -0.22; 237 participants; 4 studies; very low-quality evidence), total hospital stay (MD -2.42 days, 95% CrI -3.91 to -0.94; 197 participants; 3 studies; very low-quality evidence), and operating time (MD -15.32 minutes, 95% CrI -29.03 to -1.69; 192 participants; 4 studies; very low-quality evidence) were lower with low central venous pressure than with control. For the other comparisons, the evidence for difference was either based on single small trials or there was no evidence of differences. None of the trials reported health-related quality of life or time needed to return to work. AUTHORS' CONCLUSIONS Paucity of data meant that we could not assess transitivity assumptions and inconsistency for most analyses. When direct and indirect comparisons were available, network meta-analysis provided additional effect estimates for comparisons where there were no direct comparisons. However, the paucity of data decreases the confidence in the results of the network meta-analysis. Low-quality evidence suggests that liver resection using a radiofrequency dissecting sealer may be associated with more adverse events than with the clamp-crush method. Low-quality evidence also suggests that the proportion of people requiring a blood transfusion is higher with low central venous pressure than with acute normovolemic haemodilution plus low central venous pressure; very low-quality evidence suggests that blood transfusion quantity (red blood cells) was lower with fibrin sealant than control; blood transfusion quantity (fresh frozen plasma) was higher with oxidised cellulose than with fibrin sealant; and blood loss, total hospital stay, and operating time were lower with low central venous pressure than with control. There is no evidence to suggest that using special equipment for liver resection is of any benefit in decreasing the mortality, morbidity, or blood transfusion requirements (very low-quality evidence). Radiofrequency dissecting sealer should not be used outside the clinical trial setting since there is low-quality evidence for increased harm without any evidence of benefits. In addition, it should be noted that the sample size was small and the credible intervals were wide, and we cannot rule out considerable benefit or harm with a specific method of liver resection.
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Affiliation(s)
- Elisabetta Moggia
- IRCCS Humanitas Research HospitalDepartment of General and Digestive SurgeryVia Manzoni 5620089 RozzanoMilanItalyItaly20089
| | - Benjamin Rouse
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Constantinos Simillis
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Tianjing Li
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Jessica Vaughan
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Guo L, Wang W, Zhao N, Guo L, Chi C, Hou W, Wu A, Tong H, Wang Y, Wang C, Li E. Mechanical ventilation strategies for intensive care unit patients without acute lung injury or acute respiratory distress syndrome: a systematic review and network meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:226. [PMID: 27448995 PMCID: PMC4957383 DOI: 10.1186/s13054-016-1396-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/29/2016] [Indexed: 01/25/2023]
Abstract
Background It has been shown that the application of a lung-protective mechanical ventilation strategy can improve the prognosis of patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). However, the optimal mechanical ventilation strategy for intensive care unit (ICU) patients without ALI or ARDS is uncertain. Therefore, we performed a network meta-analysis to identify the optimal mechanical ventilation strategy for these patients. Methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, MEDLINE, CINAHL, and Web of Science for studies published up to July 2015 in which pulmonary compliance or the partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FIO2) ratio was assessed in ICU patients without ALI or ARDS, who received mechanical ventilation via different strategies. The data for study characteristics, methods, and outcomes were extracted. We assessed the studies for eligibility, extracted the data, pooled the data, and used a Bayesian fixed-effects model to combine direct comparisons with indirect evidence. Results Seventeen randomized controlled trials including a total of 575 patients who received one of six ventilation strategies were included for network meta-analysis. Among ICU patients without ALI or ARDS, strategy C (lower tidal volume (VT) + higher positive end-expiratory pressure (PEEP)) resulted in the highest PaO2/FIO2 ratio; strategy B (higher VT + lower PEEP) was associated with the highest pulmonary compliance; strategy A (lower VT + lower PEEP) was associated with a shorter length of ICU stay; and strategy D (lower VT + zero end-expiratory pressure (ZEEP)) was associated with the lowest PaO2/FiO2 ratio and pulmonary compliance. Conclusions For ICU patients without ALI or ARDS, strategy C (lower VT + higher PEEP) was associated with the highest PaO2/FiO2 ratio. Strategy B (higher VT + lower PEEP) was superior to the other strategies in improving pulmonary compliance. Strategy A (lower VT + lower PEEP) was associated with a shorter length of ICU stay, whereas strategy D (lower VT + ZEEP) was associated with the lowest PaO2/FiO2 ratio and pulmonary compliance. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1396-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lei Guo
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Weiwei Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Nana Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Libo Guo
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Chunjie Chi
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Wei Hou
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Anqi Wu
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Hongshuang Tong
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Yue Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China
| | - Changsong Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Enyou Li
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, No 23 Youzheng St., Nangang District, Harbin, Heilongjiang, 150001, China.
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Nagendran M, Maruthappu M, Gordon AC, Gurusamy KS. Comparative safety and efficacy of vasopressors for mortality in septic shock: A network meta-analysis. J Intensive Care Soc 2016; 17:136-145. [PMID: 28979478 PMCID: PMC5606402 DOI: 10.1177/1751143715620203] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Septic shock is a life-threatening condition requiring vasopressor agents to support the circulatory system. Several agents exist with choice typically guided by the specific clinical scenario. We used a network meta-analysis approach to rate the comparative efficacy and safety of vasopressors for mortality and arrhythmia incidence in septic shock patients. METHODS We performed a comprehensive electronic database search including Medline, Embase, Science Citation Index Expanded and the Cochrane database. Randomised trials investigating vasopressor agents in septic shock patients and specifically assessing 28-day mortality or arrhythmia incidence were included. A Bayesian network meta-analysis was performed using Markov chain Monte Carlo methods. RESULTS Thirteen trials of low to moderate risk of bias in which 3146 patients were randomised were included. There was no pairwise evidence to suggest one agent was superior over another for mortality. In the network meta-analysis, vasopressin was significantly superior to dopamine (OR 0.68 (95% CI 0.5 to 0.94)) for mortality. For arrhythmia incidence, standard pairwise meta-analyses confirmed that dopamine led to a higher incidence of arrhythmias than norepinephrine (OR 2.69 (95% CI 2.08 to 3.47)). In the network meta-analysis, there was no evidence of superiority of one agent over another. CONCLUSIONS In this network meta-analysis, vasopressin was superior to dopamine for 28-day mortality in septic shock. Existing pairwise information supports the use of norepinephrine over dopamine. Our findings suggest that dopamine should be avoided in patients with septic shock and that other vasopressor agents should continue to be based on existing guidelines and clinical judgement of the specific presentation of the patient.
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Affiliation(s)
- Myura Nagendran
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Mahiben Maruthappu
- North West Thames Foundation School, Imperial College London, London, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
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Nadalin S, Capobianco I, Königsrainer A. [Vascular management in anatomical liver resection]. Chirurg 2015; 86:121-4. [PMID: 25604305 DOI: 10.1007/s00104-014-2882-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The vascular management in anatomical liver resection plays a pivotal role in maintaining an adequately functional residual liver volume. In this respect it is essential to guarantee an adequate portal and arterial inflow as well venous outflow for the whole residual liver (lobe or segments). To achieve this, the liver surgeon should have excellent perioperative imaging, surgical expertise based on knowledge of vascular anatomy, physiology and hemodynamics of the liver and a well-designed and cautious operative strategy. The use of intraoperative ultrasonography (with or without contrast enhancement) and modern parenchymal dissectors (e.g. ultrasound or water jet dissectors) are strongly recommended.
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Affiliation(s)
- S Nadalin
- Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Universitätsklinikum Tübingen, Hoppe Seyler Str. 3, 72076, Tübingen, Deutschland
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Wang C, Zhao N, Wang W, Guo L, Guo L, Chi C, Wang X, Pi X, Cui Y, Li E. Intraoperative mechanical ventilation strategies for obese patients: a systematic review and network meta-analysis. Obes Rev 2015; 16:508-17. [PMID: 25788167 DOI: 10.1111/obr.12274] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 12/09/2014] [Accepted: 02/11/2015] [Indexed: 11/27/2022]
Abstract
Several intraoperative ventilation strategies are available for obese patients. However, the same ventilation interventions have exhibited different effects on PaO2 /FIO2 concerning obese patients in different trials, and the issue remains controversial. Therefore, we conducted a network meta-analysis to identify the optimal mechanical ventilation strategy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Embase, MEDLINE, CINAHL and Web of Science for studies published up to June 2014, and the PaO2 /FIO2 in obese patients given different mechanical ventilation strategies was assessed. We assessed the studies for eligibility and extracted data and then pooled the data and used a Bayesian fixed-effect model to combine direct comparisons with indirect evidence. Eligible studies evaluated different ventilation strategies for obese patients and reported the intraoperative PaO2 /FIO2 ratio, atelectasis and pulmonary compliance. Thirteen randomized controlled trials were included for network meta-analysis, including 476 patients who received 1 of 12 ventilation strategies. Volume-controlled ventilation with higher PEEP plus single recruitment manoeuvres (VCV + higher PEEP + single RM) was associated with the highest PaO2 /FiO2 ratio, improving intraoperative pulmonary compliance and reducing the incidence of intraoperative atelectasis.
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Affiliation(s)
- C Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - N Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - W Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Libo Guo
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lei Guo
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - C Chi
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - X Wang
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - X Pi
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Y Cui
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - E Li
- Department of Anesthesiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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Wang C, Guo L, Chi C, Wang X, Guo L, Wang W, Zhao N, Wang Y, Zhang Z, Li E. Mechanical ventilation modes for respiratory distress syndrome in infants: a systematic review and network meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:108. [PMID: 25881121 PMCID: PMC4391657 DOI: 10.1186/s13054-015-0843-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 02/24/2015] [Indexed: 12/02/2022]
Abstract
Introduction The effects of different mechanical ventilation (MV) modes on mortality outcome in infants with respiratory distress syndrome (RDS) are not well known. Methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, MEDLINE, CINAHL, and Web of Science for studies published through April 2014 that assessed mortality in infants with RDS given different MV modes. We assessed studies for eligibility, extracted data, and subsequently pooled the data. A Bayesian fixed-effects model was used to combine direct comparisons with indirect evidence. We also performed sensitivity analyses and rankings of the competing treatment modes. Results In total, 20 randomized controlled trials were included for the network meta-analysis, which consisted of 2,832 patients who received one of 16 ventilation modes. Compared with synchronized intermittent mandatory ventilation (SIMV) + pressure support ventilation (PSV), time-cycled pressure-limited ventilation (TCPL) (hazard ratio (HR) 0.290; 95% confidence interval (CI) 0.071 to 0.972), high-frequency oscillatory ventilation (HFOV) (HR 0.294; 95% CI 0.080 to 0.852), SIMV + volume-guarantee (VG) (HR 0.122; 95% CI 0.014 to 0.858), and volume-controlled (V-C) (HR 0.139; 95% CI 0.024 to 0.677) ventilation modes are associated with lower mortality. The combined results of available ventilation modes were not significantly different in regard to the incidences of patent ductus arteriosus and intraventricular hemorrhage. Conclusion Compared with the SIMV + PSV ventilation mode, the TCPL, HFOV, SIMV + VG, and V-C ventilation modes are associated with lower mortality. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0843-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Changsong Wang
- Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Str, Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Libo Guo
- Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Str, Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Chunjie Chi
- Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Str, Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Xiaoyang Wang
- Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Str, Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Lei Guo
- Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Str, Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Weiwei Wang
- Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Str, Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Nana Zhao
- Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Str, Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Yibo Wang
- Department of Implantology, Hospital of Stomatology, Harbin Medical University, No 23 Youzheng Str, Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Zhaodi Zhang
- Department of Anesthesiology, The Third Affiliated Hospital of Harbin Medical University, No 150 Haping Str, Nangang District, Harbin, Heilongjiang, 150001, China.
| | - Enyou Li
- Department of Anesthesiology, First Affiliated Hospital of Harbin Medical University, No 23 Youzheng Str, Nangang District, Harbin, Heilongjiang, 150001, China.
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11
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Abstract
Techniques in liver surgery have improved considerably during the last decades, allowing for liver resections with low morbidity and mortality. Preoperative patient selection, perioperative management, and intraoperative blood-sparing techniques are the cornerstones of modern liver surgery. Multimodal treatment of colorectal liver metastases has expanded the group of patients who are potential candidates for liver resection. Adjunctive techniques, including preoperative portal vein embolization and staged hepatectomy, have facilitated the safe performance of extensive liver resection. This article provides an overview of indications for liver resection and a systematic description of the technical approach to the most commonly performed resections.
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Affiliation(s)
- Christoph W Michalski
- Division of Surgical Oncology, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Kevin G Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
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12
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Kim G, Baik SK. Overview and recent trends of systematic reviews and meta-analyses in hepatology. Clin Mol Hepatol 2014; 20:137-50. [PMID: 25032179 PMCID: PMC4099328 DOI: 10.3350/cmh.2014.20.2.137] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/29/2014] [Indexed: 12/12/2022] Open
Abstract
A systematic review (SR) is a research methodology that involves a comprehensive search for and analysis of relevant studies on a specific topic. A strict and objective research process is conducted that comprises a systematic and comprehensive literature search in accordance with predetermined inclusion/exclusion criteria, and an assessment of the risk of bias of the selected literature. SRs require a multidisciplinary approach that necessitates cooperation with clinical experts, methodologists, other experts, and statisticians. A meta-analysis (MA) is a statistical method of quantitatively synthesizing data, where possible, from the primary literature selected for the SR. Review articles differ from SRs in that they lack a systematic methodology such as a literature search, selection of studies according to strict criteria, assessment of risk bias, and synthesis of the study results. The importance of evidence-based medicine (EBM) in the decision-making for public policy has recently been increasing thanks to the realization that it should be based on scientific research data. SRs and MAs are essential for EBM strategy and evidence-based clinical practice guidelines. This review addresses the current trends in SRs and MAs in the field of hepatology via a search of recently published articles in the Cochrane Library and Ovid-MEDLINE.
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Affiliation(s)
- Gaeun Kim
- Department of Nursing, Keimyung University College of Nursing, Daegu, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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