Transcatheter, sutureless and conventional aortic-valve replacement: a network meta-analysis of 16,432 patients.

BACKGROUND: Minimally invasive surgical techniques pose alternatives to conventional surgery for the treatment of aortic stenosis (AS). We present a Bayesian network analysis comparing Valve Academic Research Consortium-2 clinical outcomes between transcatheter aortic valve implantation (TAVI), sutureless (SL-AVR) and conventional aortic valve replacement (CAVR). METHODS: Electronic searches of databases were conducted and seven two-arm randomized-controlled trials and 25 propensity-score-matched studies comparing clinical outcomes of TAVI, SL-AVR and CAVR for treatment of AS were identified. Bayesian Markov chain Monte Carlo modelling was used to analyze clinical outcomes. RESULTS: The analysis included 16,432 patients who underwent TAVI [7,056], SL-AVR [1,238] or CAVR [8,138]. Compared to CAVR, TAVI and SL-AVR were associated with reduced postoperative major bleeding of 59% (OR 0.41, 95% CI: 0.28-0.59) and 44% (OR 0.56, 95% CI: 0.30-0.99) respectively. TAVI had a 41% reduction in postoperative myocardial infarction (OR 0.59, 95% CI: 0.40-0.86) and SL-AVR had a 40% reduction in postoperative acute kidney injury (AKI) (OR 0.62, 95% CI: 0.42-0.86). Compared to TAVI, CAVR and SL-AVR had a reduction in moderate/severe paravalvular regurgitation of 89% (OR 0.11, 95% CI: 0.07-0.16) and 92% (OR 0.08, 95% CI: 0.03-0.17). CAVR had a 67% decreased postoperative permanent pacemaker (PPM) implantation compared to TAVI (OR 0.33, 95% CI: 0.24-0.45) and a 63% reduction compared to SL-AVR (OR 0.37, 95% CI: 0.22-0.61). There were no differences in 30-day mortality or postoperative stroke between the groups. CONCLUSIONS: In selected patients, minimally invasive surgical interventions including TAVI and SL-AVR for severe AS are viable alternatives to conventional surgery. However, TAVI is associated with increased paravalvular regurgitation, whereas TAVI and SL-AVR are associated with increased conduction disturbances compared to CAVR.

Orbital Apex Syndrome in Pseudomonas Sinusitis After Functional Endoscopic Sinus Surgery.

Sinusitis complicated by orbital apex syndrome is rare. The majority of cases are due to mucormycosis in immunocompromised patients. The authors report a case of orbital apex syndrome secondary to Pseudomonas sinusitis. The patient was a 79-year-old Type 2 diabetic woman who underwent left-sided functional endoscopic sinus surgery. Three months postprocedure, she presented with a 3-week history of gradual vision loss and constant temporal headache on the ipsilateral side. Examination revealed light perception vision, a relative afferent pupillary defect, absent corneal reflex, and disc pallor. Imaging revealed opacification of the posterior ethmoidal air cells extending to involve the orbital apex. Urgent orbital and sinonasal decompression was performed. Intraoperative specimens grew Pseudomonas aeruginosa. The patient was treated with liposomal amphotericin B, posaconazole, and piperacillin/tazobactam. The patient recovered with no visual sequelae. Pseudomonas is an important mimicker to consider in sinusitis causing orbital apex syndrome, and it may occur following functional endoscopic sinus surgery.

Metastasis to the extraocular muscles: a case report, literature review and pooled data analysis.

Metastasis to the extraocular muscles (EOM) is rare. The existing literature comprises only of isolated case reports therefore a summative description of these lesions is lacking. This study presents a case of bilateral rectus muscle metastasis from malignant melanoma. Furthermore a literature review and pooled data analysis is undertaken with 43 articles encompassing 77 patients and 101 eyes. Mean age was 53 years, 54% were male, 66% had unilateral involvement and 34% had bilateral involvement. The primary malignancies were melanoma (n = 17, 22%), breast (n = 15, 15%) and carcinoid (n = 11, 14%). A single muscle was involved in 56 eyes (67%) and multiple muscles in 27 eyes (33%). Lateral rectus was most commonly affected (n = 44, 53%). Presenting symptoms included restricted eye movements (n = 48, 62%), proptosis (n = 45, 58%), diplopia (n = 27, 35%) and pain (n = 18, 23%). Scattered case reports have previously made it difficult to characterise this phenomenon thus a pooled data analysis is presented.

Laminectomy and fusion vs laminoplasty for multi-level cervical myelopathy: a systematic review and meta-analysis.

BACKGROUND: Surgical approaches for multi-level cervical spondylotic myelopathy (CSM) include posterior cervical surgery via laminectomy and fusion (LF) or expansive laminoplasty (EL). The relative benefits and risks of either approach in terms of clinical outcomes and complications are not well established. A systematic review and meta-analysis was conducted to address this topic. METHODS: Electronic searches were performed using six databases from their inception to January 2016, identifying all relevant randomized controlled trials (RCTs) and non-RCTs comparing LF vs EL for multi-level cervical myelopathy. Data was extracted and analyzed according to predefined endpoints. RESULTS: From 10 included studies, there were 335 patients who underwent LF compared to 320 patients who underwent EL. There was no significant difference found postoperatively between LF and EL groups in terms of postoperative JOA (P = 0.39), VAS neck pain (P = 0.93), postoperative CCI (P = 0.32) and Nurich grade (P = 0.42). The total complication rate was higher for LF compared to EL (26.4 vs 15.4 %, RR 1.77, 95 % CI 1.10, 2.85, I 2 = 34 %, P = 0.02). Reoperation rate was found to be similar between LF and EL groups (P = 0.52). A significantly higher pooled rate of nerve palsies was found in the LF group compared to EL (9.9 vs 3.7 %, RR 2.76, P = 0.03). No significant difference was found in terms of operative time and intraoperative blood loss. CONCLUSIONS: From the available low-quality evidence, LF and EL approaches for CSM demonstrates similar clinical improvement and loss of lordosis. However, a higher complication rate was found in LF group, including significantly higher nerve palsy complications. This requires further validation and investigation in larger sample-size prospective and randomized studies.

Orbital Approaches for Treatment of Carotid Cavernous Fistulas: A Systematic Review.

BACKGROUND: Carotid cavernous fistulas (CCFs) are abnormal connections between the carotid arteries and the cavernous sinus. CCFs often present with double vision, reduced visual acuity, and conjunctivitis. Deteriorating ocular symptoms caused by abnormal fistula drainage can cause permanent blindness, and so urgent interventional treatment is necessary. Transvenous embolization of the fistula is the primary treatment option for most patients with symptomatic CCFs. Orbital approaches are considered to be risky compared with the traditional approach via the inferior petrosal sinus and are thus used as a secondary option. These approaches include embolization via the superior ophthalmic vein, inferior ophthalmic vein, and medial ophthalmic vein and direct transorbital puncture. This study aims to assess the merits and risks of orbital approaches in transvenous embolization of CCFs. METHODS: A systematic review of 30 studies assessing the radiographic and clinical outcomes of this approach was conducted. Outcomes of interest included successful fistula closure, postoperative improvement of ocular symptoms, and complications from the procedure. Weighted averages were calculated for all outcomes. RESULTS: Transvenous embolization via an orbital approach had a high success rate (89.9%). Improvement in visual acuity and proptosis was found in 93.4% and 88.1% of patients, respectively. There were no major complications. Minor complications found included subconjunctival hemorrhage (n = 4), intraorbital hemorrhage (n = 1), eyelid hematoma (n = 1), and foreign-body granuloma (n = 3). CONCLUSIONS: All orbital approaches for transvenous embolization of CCFs are effective and safe.

Bilateral versus unilateral instrumentation in spinal surgery: Systematic review and trial sequential analysis of prospective studies.

Lumbar fusion surgical intervention is often followed by bilateral pedicle screw fixation. There has been increasing support for unilateral pedicle screw fixation in an attempt to reduce complications and costs. The following study assesses the efficacy and complications of bilateral versus unilateral pedicle screw fixation in open and minimally invasive lumbar interbody fusion techniques. A systematic review with meta-analysis and trial sequential analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations. In comparison with existing meta-analyses, trial sequential analysis was implemented to reduce the potential for type I error. Of the 1310 citations screened, four observational studies and 13 randomised controlled trials were used comprising 574 bilateral cases and 549 unilateral cases. Statistical analysis showed no difference in fusion rates, total complications, dural tear rates, Visual Analogue Scale (VAS) score for back pain, VAS for leg pain, Oswestry Disability Index scores, and length of stay between bilateral and unilateral instrumentation. Unilateral instrumentation was significantly shorter in duration (P<0.00001) and led to significantly lower blood volume loss (P=0.0002). These results were the same for both open and minimally invasive surgical approaches. Unilateral pedicle screw fixation appears to have similar post-operative outcomes as bilateral fixation and improved efficacy in regards to procedure duration and blood volume loss.