title: A network meta-analysis comparing perioperative outcomes of interventions aiming to decrease ischemia reperfusion injury during elective liver resection.
abstract: OBJECTIVE
  This study sought to compare the perioperative outcomes of interventions aiming to decrease ischemia-reperfusion (IR) injury during elective liver resection.
  
  
  METHODS
  A comprehensive literature search was performed to identify randomized controlled trials. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS following the guidelines of the National Institute for Health and Clinical Excellence Decision Support Unit. Odds ratios for binary outcomes and mean differences for continuous outcomes were calculated using a fixed effect model or a random effects model according to model fit.
  
  
  RESULTS
  Forty-four trials with 2,457 patients having undergone liver resection were included and were divided into 8 classes of interventions aimed at decreasing IR injury and a control group, which was hepatectomy alone. There was no difference between the different interventions in mortality, quantity of blood transfusion, and durations of stay in an intensive therapy unit between any pairwise comparisons. Patients treated with ischemic preconditioning, cardiovascular modulators, and miscellaneous interventions had significantly fewer serious adverse events compared with patients undergoing liver resection alone. Ischemic preconditioning patients had significantly fewer transfusion proportions and shorter operative time than patients treated with steroids. Ischemic preconditioning had significantly less operative blood loss compared with all other interventions, and a lesser duration of hospital stay than hepatectomy alone. Sensitivity analysis showed that the drugs sevoflurane (a volatile anesthetic), verapamil (a calcium channel blocker), and gabexate mesilate (a thrombin inhibitor) produced fewer serious adverse events compared with hepatectomy alone.
  
  
  CONCLUSIONS
  Ischemic preconditioning resulted in multiple beneficial clinical endpoints and further RCTs seem to be needed to confirm its clinical benefits.
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK. Electronic address: csimillis@gmail.com.
authors.forename: Constantinos
authors.initials: C
authors.lastname: Simillis
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK.
authors.forename: Francis P
authors.initials: FP
authors.lastname: Robertson
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK.
authors.forename: Thalia
authors.initials: T
authors.lastname: Afxentiou
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK.
authors.forename: Brian R
authors.initials: BR
authors.lastname: Davidson
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK.
authors.forename: Kurinchi S
authors.initials: KS
authors.lastname: Gurusamy
mesh_terms: D001499:Bayes Theorem; D003131:Combined Modality Therapy; D017558:Elective Surgical Procedures; D006498:Hepatectomy; D006801:Humans; D019194:Ischemic Preconditioning; D008390:Markov Chains; D015233:Models, Statistical; D009010:Monte Carlo Method; D019990:Perioperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D015427:Reperfusion Injury / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome