Strategies for minimizing blood loss during craniosynostosis surgeries: A Bayesian network meta-analysis

Abstract

Children with craniosynostosis might require surgical management to prevent serious complications such as increased intracranial pressure and developmental delays. The surgical poses the risk of blood loss, which could lead to post-surgical complications that may necessitate blood transfusions and increase perioperative morbidity. The aim of this meta-analysis was to explore strategies for minimizing blood loss during craniosynostosis surgeries. A systematic literature search was performed on PubMed, Scilit, Scopus, and Web of Science for studies published as of March 7, 2024. Studies were deemed eligible if they reported intraoperative blood loss during surgeries employing the following techniques: first-pass fluid outflow drainage optimization (1pFODO), second-pass fluid outflow drainage optimization (2pFODO), cranial vault remodeling (CVR), endoscopic strip craniectomy (ES), strip craniectomy (SC), and frontal orbital advancement and remodeling (FOAR). Bayesian network meta-analysis was employed to compare these techniques using a random-effects model, where pooled estimates were expressed as standard mean difference (SMD) and its 95% confidence interval (95% CI). Five studies were included in the systematic review and meta-analysis after screening 1,473 initially identified records. A total of 296 patients aged 3.1 to 96 months were recruited across studies from various countries, including South Korea, the United States, Turkey, and the United Kingdom. Blood loss during surgery varied from 1.4±4.5 mL to 151.3±51.2 mL. Compared to CVR, the SMDs for 2pFODO, 1pFODO, SC, and ES were -0.99 (95%CI: -140 to 120), -1.1 (95%CI: -91 to 83), -1.5 (95%CI: -66 to 61), and -2.8 (95%CI: -91 to 83), respectively. ES and SC had the highest rank probabilities for being the best techniques in minimizing blood loss, with probability value of 0.464 and 0.305, respectively. When the analysis focused specifically on non-syndromic cases, ES showed the greatest reduction in blood loss compared to CVR (SMD: -2.8 (95%CI: -174.5 to 163.4), with a probability score of 0.315. In conclusion, ES performs the best in minimizing blood loss in both mixed and non-syndromic cases. Surgeons may consider other factors when selecting a surgical technique, such as cephalic index, skull maturity, reoperation rate, surgical complexity, and long-term neurodevelopmental outcomes.