No abstract available
Systematic review and meta-analysis: techniques and a guide for the academic surgeon
With the rapidly growing literature across the surgical disciplines, there is a corresponding need to critically appraise and summarize the currently available evidence so they can be applied appropriately to patient care. The interpretation of systematic reviews is particularly challenging in cases where few robust clinical trials have been performed to address a particular question. However, risk of bias can be minimized and potentially useful conclusions can be drawn if strict review methodology is adhered to, including an exhaustive literature search, quality appraisal of primary studies, appropriate statistical methodology, assessment of confidence in estimates and risk of bias. Therefore, the following article aims to: (I) summarize to the important features of a thorough and rigorous systematic review or meta-analysis for the surgical literature; (II) highlight several underused statistical approaches which may yield further interesting insights compared to conventional pair-wise data synthesis techniques; and (III) propose a guide for thorough analysis and presentation of results.
Hand-held spectral-domain optical coherence tomography of small macular retinoblastoma in infants before and after chemotherapy
Purpose: To demonstrate the utility of hand-held spectral-domain optical coherence tomography (SD-OCT) in assessing retinal structure in cases of macular retinoblastoma.
Methods: In this retrospective, observational case series, three young children with macular retinoblastoma were treated at a tertiary care hospital. At examination under anesthesia, each patient was evaluated with SD-OCT for analysis of retinal tumor and macula. The main outcomes were retinal morphology before and after chemotherapy.
Results: The mean patient age was 16 months (median: 9 months; range: 7 to 33 months). All patients had small exophytic macular retinoblastoma with subretinal fluid in the foveola. At presentation, the mean tumor thickness was 4.8 mm (range: 4.0 to 6.0 mm) and mean tumor base was 10.3 mm (range: 8.0 to 12.0 mm). SD-OCT documented tumor surface as smooth (n = 2) or irregular (n = 1), involvement of full-thickness retina (n = 3), and optical density as low (n = 3). The surrounding retina showed abrupt transition to tumor (n = 3), without intraretinal edema (n = 3), and with underlying subretinal fluid (n = 3). Following chemotherapy, all tumors showed regression with mean thickness of 2.6 mm (range: 2.2 to 3.0 mm). SD-OCT documented tumor surface as smooth (n = 1) or irregular (n = 2), and optical density as medium (n = 1) or high (n = 2). At the tumor site, the retina showed full-thickness disorganization but with abrupt transition to normal retina (n = 3). The foveola was anatomically intact (n = 1) or with outer retinal thinning (n = 2). Subretinal fluid was resolved in each case (n = 3).
Conclusions: SD-OCT can provide precise anatomic monitoring of the macular region in infants and young children with small macular retinoblastoma. This may serve as a guide for visual potential in the preverbal child
Could less be more?-A systematic review and meta-analysis of sublobar resections versus lobectomy for non-small cell lung cancer according to patient selection
Objectives: There is renewed interest in performing segmentectomies and wedge resections for selected patients with early-stage non-small cell lung cancer. However, comparative data on sublobar resections versus lobectomies include ‘intentionally selected’ patients who could tolerate either procedure, or ‘compromised’ patients who could only undergo sublobar resections due to significant comorbidities or insufficient cardiopulmonary reserve. To address this important point, the present meta-analysis aimed to compare the survival outcomes of sublobar resections and segmentectomies versus lobectomies based on patient selection and surgical intent.
Methods: A systematic review was performed using 6 online databases to identify all comparative studies that presented survival data on sublobar resections versus lobectomy procedures. These studies were then categorized according to the patient selection process for those who underwent sublobar resections. Patients were considered ‘intentionally selected’ if they could have tolerated either procedure, ‘compromised’ if they underwent a sublobar resection due to ineligibility for a lobectomy, or ‘non-specified’.
Results: Fifty-four studies, including a single randomized controlled trial, involving 38,959 patients were found to meet the predefined selection criteria. For sublobar resections, comparative data demonstrated no significant difference in overall survival in the ‘intentionally selected’ group, but a significantly worse outcome for sublobar resections in the ‘compromised group’. Similarly, for the comparison of segmentectomies versus lobectomies, available data demonstrated no significant difference in overall survival in the ‘intentionally selected’ group, but a significantly worse outcome for segmentectomy in the ‘compromised group’.
Conclusions: The present meta-analysis was the first to emphasize the patient selection process to compare ‘intentionally selected’ and ‘compromised’ patients who underwent sublobar resections versus lobectomies. Our results suggested that segmentectomies may be a feasible alternative for selected patients who could tolerate either procedure. These patients generally had tumours that were <2cm, located peripherally with favourable histopathology, and with ground-glass opacity on imaging.
Surgical Management of Malignant Pleural Mesothelioma: An Update of Clinical Evidence
To investigate the surgical management of malignant pleural mesothelioma, 2 randomized controlled trials have been completed. We discuss the findings from these trials and the current evidence of various surgical techniques to treat this challenging disease.
Systematic review of percutaneous interventions for malignant pericardial effusion
The present systematic review assessed the safety and efficacy of percutaneous interventions for malignant pericardial effusion (MPE), with primary endpoint of recurrence of pericardial effusion. Electronic searches of six databases identified thirty-one studies, reporting outcomes following isolated pericardiocentesis (n=305), pericardiocentesis followed by extended catheter drainage (n=486), pericardial instillation of sclerosing agents (n=392) or percutaneous balloon pericardiotomy (PBP) (n=157). Isolated pericardiocentesis demonstrated a pooled recurrence rate of 38.3%. Pooled recurrence rates for extended catheter drainage, pericardial sclerosis and PBP were 12.1%, 10.8% and 10.3%, respectively. Procedure-related mortality ranged from 0.5-1.0% across the percutaneous interventions. Although isolated pericardiocentesis can safely deliver immediate symptomatic relief, subsequent catheter drainage or sclerotherapy are required to minimize recurrence. PBP has been shown to be highly effective and may be particularly useful in managing recurrent effusions. Ultimately, the choice of intervention must be based on the clinical status of patients, their underlying malignancy and the expertise available.
Surgery versus SABR for resectable non-small-cell lung cancer
No abstract available
A meta-analysis of robotic vs. conventional mitral valve surgery
Objectives: The present study is the first meta-analysis to compare the surgical outcomes of robotic vs. conventional mitral valve surgery in patients with degenerative mitral valve disease.
Methods: A systematic review of the literature was conducted to identify all relevant studies with comparative data on robotic vs. conventional mitral valve surgery. Predefined primary endpoints included mortality, stroke and reoperation for bleeding. Secondary endpoints included cross-clamp time, cardiopulmonary bypass time, length of hospitalization and duration of intensive care unit (ICU) stay. Echocardiographic outcomes were assessed when possible.
Results: Six relevant retrospective studies with comparative data for robotic vs. conventional mitral valve surgery were identified from the existing literature. Meta-analysis demonstrated a superior perioperative survival outcome for patients who underwent robotic surgery. Incidences of stroke and reoperation were not statistically different between the two treatment arms. Patients who underwent robotic surgery required a significantly longer period of cardiopulmonary bypass time and cross-clamp time. However, the lengths of hospitalization and ICU stay were not significantly different. Both surgical techniques appeared to achieve satisfactory echocardiographic outcomes in the majority of patients.
Conclusions: Current evidence on comparative outcomes of robotic vs. conventional mitral surgery is limited, and results of the present meta-analysis should be interpreted with caution due to differing patient characteristics. However, it has been demonstrated that robotic mitral valve surgery can be safely performed by expert surgeons for selected patients. A successful robotic program is dependent on a specially trained team and a sufficient volume of referrals to attain and maintain safety.
