Tranexamic acid in endoscopic sinus and skull base surgery: A systematic review and meta-analysis

Endoscopic sinus surgery (ESS) and endoscopic skull base surgery (ESBS) approaches have revolutionized the management of sinonasal and intracranial pathology. Maintaining surgical hemostasis is essential as bleeding can obscure the visibility of the surgical field, thus increasing surgical duration, risk of complications, and procedural failure. Tranexamic acid (TXA) acts to reduce bleeding by inhibiting fibrin degradation. This review aims to assess whether TXA improves surgical field quality and reduces intraoperative blood loss compared with control.

We searched PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library from inception until September 1, 2022. Two reviewers independently screened citations, extracted data, and assessed methodological quality using the Cochrane risk-of-bias tool for randomized trials. Data were pooled using a random-effect model, with continuous data presented as mean differences and dichotomous data presented as odds ratios.

Seventeen ESS randomized controlled trials (n = 1377) and one ESBS randomized controlled trial (n = 50) were reviewed. Significant improvement in surgical field quality was achieved with both systemic TXA (six studies, p < 0.00001) and topical TXA (six studies, p = 0.01) compared with the control. Systemic TXA (eight studies) and topical TXA (three studies) both achieved a significant reduction in intraoperative blood loss compared with the control (p < 0.00001). There were significant differences in operative times (p < 0.001) but no significant difference in perioperative outcomes (p = 0.30).

This meta-analysis demonstrated that the administration of TXA in ESS can improve surgical field quality and reduce intraoperative blood loss. TXA use did not result in increased perioperative complications including thrombotic events.