Tranexamic acid in endoscopic sinus surgery: an updated systematic review and meta-analysis of randomized controlled trials

To conduct an updated meta-analysis evaluating the efficacy and safety of tranexamic acid (TXA) versus control during endoscopic sinus surgery.

Six databases were screened until July 7, 2024, and the quality of included randomized controlled trials (RCTs) was assessed. Endpoints were summarized as mean difference (MD) with 95% confidence intervals (CIs) using a random-effects model.

A total of 23 RCTs, including 29 arms and 1597 patients, were analyzed. The overall quality was rated as low-risk in 15 RCTs, high-risk in five RCTs, and of some concern in three RCTs. TXA significantly reduced intraoperative blood loss (n = 22 arms, MD = − 68.87 ml, 95% CI − 79.66, − 58.07) and operative time (n = 21 arms, MD = − 13.93 min, 95% CI − 17.49, − 10.37) compared to control. TXA also improved surgical field quality (measured on a 5-point Boezaart scale, n = 22 arms, MD = − 0.61, 95% CI − 0.88, − 0.34) and surgeon satisfaction scores (n = 9 arms, MD = 0.85, 95% CI 0.53, 1.17). No thromboembolic events were reported in either group. Leave-one-out sensitivity analyses confirmed the robustness of all endpoints, and no publication bias was detected. Subgroup analyses by route of administration (intravenous, topical, and oral) showed equal effectiveness. Additionally, analyses by sinus pathology demonstrated effectiveness in patients with severe chronic rhinosinusitis with nasal polyposis (CRSwNP). Trial sequential analysis showed conclusiveness for all outcomes.

Perioperative TXA, whether administered systemically or topically, correlates with decreased intraoperative blood loss, shortened operating times, and enhanced surgical visualization compared to control interventions. However, these findings are constrained by significant heterogeneity and varying reporting quality among studies.