Network meta-analysis of topical haemostatic agents in thyroid surgery

Polychronidis, Georgios; Hüttner, Felix J; Contin, Pietro; Goossen, Käthe; Uhlmann, Lorenz; Heidmann, Marianne; Knebel, Phillip; Büchler, Markus W.; Probst, Pascal

doi:10.1002/bjs.10975

Cited by 20 publications

(18 citation statements)

References 41 publications

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“…The rate of postoperative bleeding in our patient cohort (2.4%) is consistent with the described rates in the literature (0 to 9.1%) 4 .…”

Section: Discussionsupporting

confidence: 92%

“…The use of hemostatic agents in thyroid surgery has been widely reported in the literature, but their effectiveness in preventing postoperative bleeding remains controversial 17 . Considering biologically active agents only, some studies demonstrated an advantage over standard treatment in terms of mean operation time, reduction of 24-h drain output, time to drain removal, incidence of post-operative seroma and length of hospital stay 1,3,4,[18][19][20][21][22] . Others found a lack of advantages on reducing perioperative bleeding, time to drain removal and length of hospital stay 23,24 , causing only additional costs 24 .…”

mentioning

confidence: 99%

“…Furthermore, Testini et al and Scerrino et al found that both biologically active and physical hemostatic agents reduced the mean operation time and the 24-h drain output, with the first ones being more effective 3,21 . However, physical agents didn't show advantages over conventional surgical techniques on time to drain removal, length of hospital stay and seroma formation 3,4,21 . We found no studies proving physical agents being more efficient than biologically active ones 1,3,4,21 .…”

mentioning

confidence: 99%

“…However, physical agents didn't show advantages over conventional surgical techniques on time to drain removal, length of hospital stay and seroma formation 3,4,21 . We found no studies proving physical agents being more efficient than biologically active ones 1,3,4,21 . Only Amit et al found that the use of an oxidized cellulose hemostatic agent resulted in longer time to drain removal, and consequently in length of hospital stay, if compared with conventional procedures, suggesting that postoperative hemorrhage can best be prevented by proper intraoperative hemostasis 25 .…”

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confidence: 99%

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Effectiveness of hemostatic agents in thyroid surgery for the prevention of postoperative bleeding

Scaroni¹,

Holzen

Nebiker

2020

Sci Rep

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Postoperative bleeding remains one of the most frequent, but rarely life-threatening complications in thyroid surgery. Although arterial bleeding is the main cause of postoperative hemorrhage, most often no actively bleeding vessel can be found during revision. Therefore, the coagulation technique for larger vessels may play a minor role, and hemostatic agents could be of higher importance. In this descriptive, retrospective study, data of 279 patients with thyroid surgery (total of 414 thyroid lobectomies) were collected. We reviewed the electronic medical record by analyzing the histological, operative, laboratory and discharge reports in regards to postoperative bleeding. Of the 414 operated thyroid lobes, 2.4% (n = 10) bled. 1.4% (n = 6) needed reoperation while the other 1.0% (n = 4) could be treated conservatively. Hemostatic patches were applied 286 (69.1%) times. Of the 128 (30.9%) patch-free operated sides, 4.7% (n = 6) suffered postoperative bleeding. Tachosil ® alone was used 211 (51.0%) times and bleeding occurred in 1.4% (n = 3). Without statistical significance (p = 0.08) the use of Tachosil ® seems to help preventing postoperative bleeding. The combination with other patches doesn't appear to be more efficient. Due to its endocrine function, the thyroid gland is a well perfused organ. For this reason, a good hemostasis during surgical procedures is of utmost importance. Postoperative bleeding remains one of the most frequent complications, and can cause airway compression and respiratory distress in severe cases. Moreover, intraoperative bleeding can obscure important structures like the parathyroid glands and the recurrent laryngeal nerve, complicating surgical dissection and increasing morbidity Aleksandar, et al. 1-3. The frequency of postoperative cervical hematoma (PCH) in thyroid surgery requiring reoperation ranges from 0 to 9.1% 4 , and it is the most common reason for return to the operating room 5. Many factors influence perioperative hemostasis. In the literature, several preoperative patient's risk factors are described, such as Grave's disease 6-9 , benign pathology 6,8,9 , the use of anticoagulation or antiplatelet medication while doing surgery 6,10 , an increased size of the pathology specimen 6 , an emergent admission 8 , presence of 2 or more comorbidities 8 , previous thyroid surgery 9 , age 65 years and older 7,11 , African-American race 7 and history of alcohol abuse 7. A BMI greater than 30 kg/m 2 11,12 and male sex 7,9,11 are also independent risk factors associated with PCH. Furthermore, postoperative hypertension increases the risk of postoperative bleeding 9,13. In the past century, the only instruments at a surgeon's disposal to obliterate vessels were needle and thread in order to create a ligation. Nowadays, the industry provides a variety of devices to seal and cut vessels, such as metal clips, bipolar coagulation forceps (e.g. BiClamp ®) and ultrasound scissors. The type of sealing technique doesn't seem to affect the risk of postoperative bleeding. Alesina et al. and...

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“…The rate of postoperative bleeding in our patient cohort (2.4%) is consistent with the described rates in the literature (0 to 9.1%) 4 .…”

Section: Discussionsupporting

confidence: 92%

mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Effectiveness of hemostatic agents in thyroid surgery for the prevention of postoperative bleeding

Scaroni¹,

Holzen

Nebiker

2020

Sci Rep

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“…Topical agents including fibrin sealants (fibrinogen and thrombin), gelatine–thrombin matrices and oxidized cellulose may be applied to bleeding tissues during surgery as a haemostatic strategy. However, these agents are expensive and, despite numerous studies across different surgical specialties, there is only weak evidence to suggest that they offer a clinically important reduction in blood loss.…”

Section: Surgical Strategiesmentioning

confidence: 99%

Strategies to minimize intraoperative blood loss during major surgery

Shah

Palmer

Klein

2020

British Journal of Surgery

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Background Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies. Methods This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient. Results Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays. Conclusion Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high‐quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.

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