BackgroundRegional citrate or heparin is often prescribed as an anticoagulant for continuous renal replacement therapy (CRRT). However, their efficacy and safety remain controversial. Therefore, we performed this meta-analysis to compare these two agents and to determine whether the currently available evidence is sufficient and conclusive by using trial sequential analysis (TSA).MethodsWe searched for relevant studies in PubMed, Embase, the Cochrane Library databases and the China National Knowledge Infrastructure (CNKI) Database from database inception until September 2015. We selected randomized controlled trials comparing regional citrate with heparin in adult patients with acute kidney injury (AKI) who were prescribed CRRT.ResultsFourteen trials (n = 1134) met the inclusion criteria. Pooled analyses showed that there was no difference in mortality between the regional citrate and heparin groups (relative risk (RR) 0.97, 95 % confidence interval (CI) 0.84, 1.13, P > 0.05), which was confirmed by TSA. Compared with heparin, regional citrate significantly prolonged the circuit life span in the continuous venovenous haemofiltration (CVVH) subgroup (mean difference (MD) 8.18, 95 % CI 3.86, 12.51, P < 0.01) and pre-dilution subgroup (MD 17.51, 95 % CI 9.85, 25.17, P < 0.01) but not in the continuous venovenous haemodiafiltration (CVVHDF) subgroup (MD 28.60, 95 % CI −3.52, 60.73, P > 0.05) or post-dilution subgroup (MD 13.06, 95 % CI −2.36, 28.48, P > 0.05). However, the results were not confirmed by TSA. A reduced risk of bleeding was found in the regional citrate compared with the systemic heparin group (RR 0.31, 95 % CI 0.19, 0.51, P < 0.01) and TSA provided conclusive evidence. Fewer episodes of heparin-induced thrombocytopoenia (HIT) (RR 0.41, 95 % CI 0.19, 0.87, P = 0.02) and a greater number of episodes of hypocalcaemia (RR 3.96, 95 % CI 1.50, 10.43, P < 0.01) were found in the regional citrate group. However, TSA did not provide conclusive evidence.ConclusionIn adult patients with AKI, there is no difference in mortality between the regional citrate and heparin treated groups. However, regional citrate is more efficacious in prolonging circuit life span and reducing the risk of bleeding and should be recommended as the priority anticoagulant for critically ill patients who require CRRT.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1299-0) contains supplementary material, which is available to authorized users.

The optimal surgical strategy for treatment of patients with synchronous colorectal liver metastases (SCLRM) remains controversial. We conducted a systematic review and metaanalysis of all observational studies to define the safety and efficacy of simultaneous versus delayed resection of the colon and liver. A search for all major databases and relevant journals from inception to April 2012 without restriction on languages or regions was performed. Outcome measures were the primary parameters of postoperative survival, complication, and mortality, as well as other parameters of blood loss, operative time, and length of hospitalization. The test of heterogeneity was performed with the Q statistic. A total of 2,880 patients were included in the meta-analysis. Long-term oncological pooled estimates of overall survival (hazard ratio [HR]: 0.96; 95% confidence interval [CI]: 0.81-1.14; P 5 0.64; I 2 5 0) and recurrence-free survival (HR: 1.04; 95% CI: 0.76-1.43; P 5 0.79; I 2 5 53%) all showed similar outcomes for both simultaneous and delayed resections. A lower incidence of postoperative complication was attributed to the simultaneous group as opposed to that in the delayed group (modified relative ratio [RR] 5 0.77; 95% CI: 0.67-0.89; P 5 0.0002; I 2 5 10%), whereas in terms of mortality within the postoperative 60 days no statistical difference was detected (RR 5 1.12; 95% CI: 0.61-2.08; P 5 0.71; I 2 5 32%). Finally, selection criteria were recommended for SCRLM patients suitable for a simultaneous resection. Conclusion: Simultaneous resection is as efficient as a delayed procedure for long-term survival. There is evidence that in SCRLM patients simultaneous resection is an acceptable and safe option with carefully selected conditions. Due to the inherent limitations of the present study, future randomized controlled trials will be useful to confirm this conclusion. (HEPATOLOGY 2013;57:2346-2357 C olorectal cancer (CRC) remains the second leading cause of cancer-related death in Western Europe and North America, and there are more than 940,000 new cases annually and nearly 500,000 deaths each year worldwide. [1][2][3] Up to 50% of patients with CRC might have liver metastases during the course of the disease, and 15% to 20% have synchronous colorectal liver metastases (SCRLM) at the time of diagnosis, whereas an additional 20% to 25% develop metachronous hepatic tumors. [4][5][6][7] The presence of liver metastases has an important influence on patient prognosis, and the median survival is 2.3 to 21.3 months for patients in whom the cancer is nonresected. 3,5,[8][9][10] Furthermore, liver resection has been accepted as the only treatment offering the chance for a cure and long-term survival, with 5-year survival rates of 25% to 60% and 10-year survival rates of 22% to 26% reported in the literature. [11][12][13][14][15][16][17][18][19] However, optimal timing of liver surgery for synchronous metastases remains controversial and continues to evolve. 20 Previously, most series reporting on the surgical management ...

These findings strongly support the link between diabetes and increased risk of cancer of biliary tract and its subsites: gallbladder cancer or extrahepatic cholangiocarcinoma, but not cancer of ampulla of Vater.