Blood loss during orthognathic surgery is variable and can be affected by the length of the procedure, major vascular injury and surgical inexperience. As a result a variety of techniques, including the use of hypotensive anesthesia, and antifibrinolytic agents have been used to reduce intra-operative blood loss. The aim of this review was to evaluate the efficacy of haemostatic adjuncts on intra-operative blood loss (IOB) in orthognathic surgery (OS)

Methods

Searches were conducted in Medline, Cochrane, Embase and the Web of Science database. Randomised controlled trials (RCTs) for the prevention of IOB in OS were considered. Two reviewers performed study selection and quality assessment independently. Quality was assessed using the Jadad scales and a Delphi list. The main outcome variable was the total IOB volume with haemoglobin haematocrit and operating time as secondary outcomes.Reductions in IOB were estimated according to the mean values and expressed as percentages for the purpose of summarising the data.

Results

• 11 RCTs were considered to be of high quality and included in the review.
• 8 trials involved antifibrinolytic agents; 4 used intravenously administered tranexamic acid (TXA), 2 topical TXA, one aprotinin, and one on the herbal medicine Yunnan Baiyao.
• 2 studies investigated hypotensive anesthesia (HA).
• 1 study examined the haemostatic effect of mandibular nerve blockage using ropivacaine (without a vasoconstrictor).
• 6 TXA studies involving 288 patients contributed to a random effects meta-analysis demonstrating an average reduction in IOB by 171 mL (95%CI; 112 to 230; P < .00001).
• Meta-analysis of 4 IV TXA studies found a reduction in IOB of 168mL (95%CI; 101 to 235 mL; P < .00001).
• Meta-analysis of 2 topical TXA studies found a reduction in IOB of 198mL (95%CI; 76 to 320; P = .001).
• A subgroup analysis showed a decreased operating time in the TXA groups by an average of 15 minutes (mean difference -14.78, 95% CI -22.21 to -7.35; P < .0001).

Conclusions

The authors concluded:

Efficient haemostatic adjuncts exist for OS. Our meta-analysis showed that TXA significantly reduces IOB by an average of one third, regardless of whether it was given intravenously (IV) or applied topically. Additional RCTs are needed to confirm the effect of topical TXA in OS, and larger studies of intravenous administration are needed before any routine recommendations. No haemostatic effect of hypotensive anesthesia was found, mainly owing to imprecise descriptions of the blinding procedures. Transparent and uniform trial reporting is thus encouraged in future studies.

Comments

This review has conducted a good search of a wide range of databases and identified a good number of RCTs. While initially 17 RCTs were included 6 lower quality studies were excluded. Study quality was assessed using two scoring scales (Jadad & Delphi). This type of scoring quality scale is no longer recommended by Cochrane, although, in this case the scores are all clearly presented for the reader to interpret. The main findings demonstrate the effectiveness of TXA to reduce bleeding in OS, which confirms the findings of an earlier review by Song et al (Dental Elf -11^th Jan 2013) that just focused on TXA only including 3 RCTs.

Links

Original Review protocol

Olsen JJ, Skov J, Ingerslev J, Thorn JJ, Pinholt EM. Prevention of Bleeding in Orthognathic Surgery-A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Oral Maxillofac Surg. 2015 May 29. pii: S0278-2391(15)00616-3. doi: 10.1016/j.joms.2015.05.031. [Epub ahead of print] Review. PubMed PMID: 26073131.

Dental Elf -11^th Jan 2013 – Review shows that tranexamic acid reduced blood loss in orthognathic surgery