title: Which hemostatic device in thyroid surgery? A network meta-analysis of surgical technologies.
abstract: BACKGROUND
  Energy-based hemostatic devices are increasingly being used in thyroid surgery. However, there are several limitations with regard to the existing evidence and a paucity of guidelines on the subject. The goal of this review is to employ the novel evidence synthesis technique of a network meta-analysis to assess the comparative effectiveness of surgical technologies in thyroid surgery and contribute to enhanced governance in the field of thyroid surgery.
  
  
  METHODS
  Articles published between January 2000 and June 2012 were identified from Embase, Medline, Cochrane Library, and PubMed databases. Randomized controlled trials of any size comparing the use of ultrasonic coagulation (harmonic scalpel) or Ligasure either head-to-head or against the "clamp-and-tie" technique were included. Two reviewers independently critically appraised and extracted the data from each study. The number of patients who experienced postoperative events was extracted in dichotomous format or continuous outcomes. Odds ratios were calculated by a Bayesian network meta-analysis, and metaregression was used for pair-wise comparisons. Indirect and direct comparisons were performed and inconsistency was assessed.
  
  
  RESULTS
  Thirty-five randomized controlled trials with 2856 patients were included. Ultrasonic coagulation ranked first (followed by Ligasure and then clamp-and-tie) with the lowest risk of postoperative hypoparathyroidism (odds ratio 1.43 [95% confidence interval (CI) 0.77-2.67] and 0.70 [CI 0.43-1.13], ultrasonic coagulation vs. Ligasure and ultrasonic coagulation vs. clamp-and-tie, respectively), least blood loss (-0.25 [CI -0.84 to -0.35] and -1.22 [CI -1.85 to -0.59]), and drain output (0.28 [CI -0.35 to -0.91] and -0.36 [CI -0.70 to -0.03]). From a health technology viewpoint, ultrasonic coagulation was associated with the shortest operative time (-0.66 [CI -1.17 to -0.14] and -1.29 [CI -1.59 to -1.00]) and hospital stay (-0.28 [CI -0.78 to 0.22] and -0.56 [CI -1.28 to 0.15]). The only exception occurs with the clinically important complication of recurrent laryngeal nerve paralysis, where the reverse trend applies (1.36 [CI 0.25-7.46] and 1.74 [CI 0.94-3.26]).
  
  
  CONCLUSIONS
  The comparative effectiveness of ultrasonic coagulation in thyroid surgery outcomes seems superior to other techniques with the exception of recurrent laryngeal nerve injury. This network meta-analysis, one of a handful in a surgical field, offers preliminary and robust evidence to guide clinical decisions and policy makers to adopt safer thyroid operations.
authors.affiliation: 1 Department of Otorhinolaryngology and Head & Neck Surgery, Imperial College London , London, United Kingdom .
authors.forename: George
authors.initials: G
authors.lastname: Garas
authors.forename: Koji
authors.initials: K
authors.lastname: Okabayashi
authors.forename: Hutan
authors.initials: H
authors.lastname: Ashrafian
authors.forename: Kunal
authors.initials: K
authors.lastname: Shetty
authors.forename: Fausto
authors.initials: F
authors.lastname: Palazzo
authors.forename: Neil
authors.initials: N
authors.lastname: Tolley
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
authors.forename: Emmanouil
authors.initials: E
authors.lastname: Zacharakis
mesh_terms: D001499:Bayes Theorem; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D057186:Comparative Effectiveness Research; D003250:Constriction; D004867:Equipment Design; D006488:Hemostasis, Surgical / Q000009:adverse effects / Q000295:instrumentation*; D006801:Humans; D007011:Hypoparathyroidism / Q000209:etiology; D007902:Length of Stay; D008026:Ligation; D008390:Markov Chains; D016017:Odds Ratio; D012307:Risk Factors; D013525:Surgical Instruments; D013961:Thyroid Gland / Q000601:surgery*; D013965:Thyroidectomy / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome; D059708:Ultrasonic Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation*; D014826:Vocal Cord Paralysis / Q000209:etiology