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American Journal of Obstetrics &... Mar 2024Cesarean scar pregnancy may lead to varying degrees of complications. There are many treatment methods for it, but there are no unified or recognized treatment... (Review)
Review
OBJECTIVE
Cesarean scar pregnancy may lead to varying degrees of complications. There are many treatment methods for it, but there are no unified or recognized treatment strategies. This systematic review and network meta-analysis aimed to observe the efficacy and safety of treatment modalities for patients with cesarean scar pregnancy.
DATA SOURCES
MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from their inception to January 31, 2024. In addition, relevant reviews and meta-analyses were manually searched for additional references.
STUDY ELIGIBILITY CRITERIA
Our study incorporated head-to-head trials involving a minimum of 10 women diagnosed with cesarean scar pregnancy through ultrasound imaging or magnetic resonance imaging, encompassing a detailed depiction of primary interventions and any supplementary measures. Trials with a Newcastle-Ottawa scale score <4 were excluded because of their low quality.
METHODS
We conducted a random-effects network meta-analysis and review for cesarean scar pregnancy. Group-level data on treatment efficacy and safety, reproductive outcomes, study design, and demographic characteristics were extracted following a predefined protocol. The quality of studies was assessed using the Cochrane risk-of-bias tools for randomized controlled trials and the Newcastle‒Ottawa scale for cohort studies and case series. The main outcomes were efficacy (initial treatment success) and safety (complications), of which summary odds ratios and the surface under the cumulative ranking curve using pairwise and network meta-analysis with random effects.
RESULTS
Seventy-three trials (7 randomized controlled trials) assessing a total of 8369 women and 17 treatment modalities were included. Network meta-analyses were rooted in data from 73 trials that reported success rates and 55 trials that reported complications. The findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage demonstrated the highest cure rates, as evidenced by surface under the cumulative ranking curve rankings of 91.2, 88.2, 86.9, and 75.3, respectively. When compared with suction curettage, the odds ratios (95% confidence intervals) for efficacy were as follows: 6.76 (1.99-23.01) for laparoscopy, 5.92 (1.47-23.78) for transvaginal resection, 5.00 (1.99-23.78) for hysteroscopic curettage, and 3.27 (1.08-9.89) for high-intensity focused ultrasound combined with suction curettage. Complications were more likely to occur after receiving uterine artery chemoembolization, suction curettage, methotrexate+hysteroscopic curettage, and systemic methotrexate; hysteroscopic curettage, high-intensity focused ultrasound combined with suction curettage, and Lap were safer than the other options derived from finite evidence; and the confidence intervals of all the data were wide.
CONCLUSION
Our findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage procedures exhibit superior efficacy with reduced complications. The utilization of methotrexate (both locally guided injection and systemic administration) as a standalone medical treatment is not recommended.
PubMed: 38485053
DOI: 10.1016/j.ajogmf.2024.101328 -
The Cochrane Database of Systematic... Feb 2024Abortions prior to 14 weeks are among the most common outpatient surgical procedures performed on people capable of becoming pregnant. Various methods have been used to... (Review)
Review
BACKGROUND
Abortions prior to 14 weeks are among the most common outpatient surgical procedures performed on people capable of becoming pregnant. Various methods have been used to control pain; however, many people still experience pain with the procedure.
OBJECTIVES
To evaluate the benefits and harms of local anaesthesia given for pain control during surgical abortion at less than 14 weeks' gestation.
SEARCH METHODS
We searched CENTRAL (Ovid EBM Reviews), MEDLINE (Ovid), Embase, POPLINE, and Google Scholar to December 2022 for randomized controlled trials of pain control in surgical abortion at less than 14 weeks' gestation using suction aspiration. We searched the reference lists of related reviews and articles.
SELECTION CRITERIA
We selected effectiveness and comparative effectiveness randomized controlled trials that studied local anaesthesia with common local anaesthetics and administration routes given for pain control in surgical abortion at less than 14 weeks' gestation using uterine aspiration. Outcomes included intraoperative pain, patient satisfaction, and adverse events.
DATA COLLECTION AND ANALYSIS
We used standard Cochrane methods. We computed mean differences (MD) with 95% confidence intervals (CI) for continuous variables reporting a mean. We assessed the certainty of evidence using GRADE.
MAIN RESULTS
Thirteen studies with 1992 participants met the inclusion criteria. Due to heterogeneity of interventions, we could not pool more than two studies for any outcome. We used 13 mm improvement on a visual/verbal analogue scale to indicate a clinically meaningful difference in pain with surgical abortion (pain with dilation, aspiration, or during procedure). Based on type of pain control, we divided studies into three groups. Paracervical block (PCB) effectiveness trials A 20 mL 1% lidocaine PCB reduced pain with dilation (MD -37.00, 95% CI -45.64 to -28.36), and aspiration (MD -26.00, 95% CI -33.48 to -18.52) compared to a sham PCB (1 RCT, 120 participants; high-certainty evidence). A PCB with 14 mL of 1% chloroprocaine resulted in a slight reduction in pain with aspiration compared to a PCB with normal saline injected at two or four sites (MD -1.50, 95% CI -2.45 to -0.55; 1 RCT, 79 participants; high-certainty evidence). PCB comparative effectiveness trials An ultracaine PCB probably results in little to no clinically meaningful difference in pain during procedure compared to topical cervical lidocaine spray (median 1 point higher, interquartile range (IQR) 0 to 3; P < 0.001; 1 RCT, 48 participants; moderate-certainty evidence). A 1000 mg dose of intravenous paracetamol probably does not decrease pain as much as ultracaine PCB during procedure (median 2 points higher, IQR 1 to 3; P < 0.001; 1 RCT, 46 participants; moderate-certainty evidence). Various local anaesthetics in PCB comparative effectiveness trials A 10 mL buffered 2% lidocaine PCB probably does not result in a clinically meaningful difference in pain with dilation compared to a plain lidocaine PCB (MD -0.80, 95% CI -0.89 to -0.71; 1 RCT, 167 participants; moderate-certainty evidence). A buffered lidocaine PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to plain lidocaine PCB (MD -0.57, 95% CI -1.01 to -0.06; 2 RCTs, 291 participants; moderate-certainty evidence). Non-PCB local anaesthesia or PCB technique effectiveness trials PCB: waiting versus no waiting Waiting three to five minutes between 1% lidocaine PCB injection and dilation probably does not result in a clinically meaningful difference in pain with dilation compared to not waiting (MD -0.70, 95% CI -1.23 to -0.17; 2 RCTs, 357 participants; moderate-certainty evidence). Topical cervical analgesia Topical 10 mL 2% lignocaine gel probably does not result in a clinically meaningful difference in pain with aspiration compared to KY Jelly (MD -0.87, 95% CI -1.60 to -0.14; 1 RCT, 131 participants; moderate-certainty evidence). In participants who also received a PCB, 20 mg topical cervical lidocaine spray probably does not result in a clinically meaningful difference in pain during the procedure compared to two pumps of normal saline spray (median -1 point, IQR -2 to -1; P < 0.001; 1 RCT, 55 participants; moderate-certainty evidence). Intravenous paracetamol 1000 mg compared to two pumps of cervical lidocaine spray probably does not results in a clinically meaningful difference in pain procedure (median 1 point, IQR -2 to 2; P < 0.001; 1 RCT, 48 participants; low-certainty evidence). Non-PCB local anaesthesia or PCB technique comparative effectiveness trials Depth of PCB The evidence suggests that a 3-cm deep PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to a 1.5-cm deep PCB (MD -1.00, 95% CI -1.09 to -0.91; 2 RCTs, 229 participants; low-certainty evidence). PCB: four sites versus two sites A two-site (4-8 o'clock) 20 mL 1% lidocaine PCB does not result in a clinically meaningful difference in pain with dilation compared to a four-site (2-4-8-10 o'clock) PCB (MD 8.60, 95% CI 0.69 to 16.51; 1 RCT, 163 participants; high-certainty evidence). Overall, participants reported moderately high satisfaction with pain control and studies reported few adverse events.
AUTHORS' CONCLUSIONS
Evidence from this updated review indicates that a 20 mL 1% plain lidocaine PCB decreases pain during an abortion procedure. Evidence supports forgoing buffering lidocaine and a wait time between PCB injection and cervical dilation. A 1.5-cm deep injection as opposed to a 3-cm deep injection is sufficient. A two-site PCB injection as opposed to a four-site injection has similar effectiveness. Topical cervical anaesthesia (10 mL 2% lignocaine gel or 20 mg topical cervical lidocaine spray) as compared to placebo did not decrease pain based on moderate-certainty evidence, but then when compared to PCB, pain control was similar. Due to this inconsistency in evidence regarding the effectiveness of topical anaesthesia, its routine use is presently not supported. This review did not include studies of pain management with conscious sedation but, based on the results of our prior Cochrane review and the 2022 WHO guidelines, we recommend that the option of combination of pain management using conscious sedation plus PCB and non-steroidal anti-inflammatory drugs should be offered where conscious sedation is available as it further decreases pain.
Topics: Pregnancy; Female; Humans; Pain Management; Anesthetics, Local; Anesthesia, Local; Acetaminophen; Carticaine; Pregnancy Trimester, First; Saline Solution; Pain; Lidocaine
PubMed: 38348912
DOI: 10.1002/14651858.CD006712.pub3 -
International Journal of Hyperthermia :... 2024Caesarean scar pregnancy (CSP) presents a significant clinical challenge owing to the associated risks of uterine scar rupture, severe haemorrhage and adverse maternal... (Meta-Analysis)
Meta-Analysis Review
Efficacy and safety of high-intensity focused ultrasound combined with suction curettage for the treatment of caesarean scar pregnancy: a systematic review and single-arm meta-analysis.
PURPOSE
Caesarean scar pregnancy (CSP) presents a significant clinical challenge owing to the associated risks of uterine scar rupture, severe haemorrhage and adverse maternal outcomes. This study aimed to assess the safety and efficacy of combining high-intensity focused ultrasound (HIFU) with suction curettage for treating CSP.
METHODS
We conducted a comprehensive search in four databases, namely PubMed, Web of Science, Embase and Cochrane Library, to identify published studies evaluating the use of HIFU combined with suction curettage to treat CSP. Intraoperative blood loss, treatment success rate, and reproductive results were the primary outcomes assessed.
RESULTS
A total of 18 studies involving 1251 patients with CSP, all of whom received preoperative HIFU therapy were included. The average hospital stay was 6.22 days, the intraoperative blood loss was 26.29 ml and the incidence of adverse events was 15.60%, including abdominal or lower limb pain, fever, vaginal bleeding, haematuria and vomiting. Furthermore, post-treatment follow-up showed that serum β-human chorionic gonadotropin levels were rapidly normalized (average of 25.48 days) and menstruation returned (average of 33.03 days). The treatment had a remarkable success rate of 97.60% and a subsequent pregnancy rate of 68.70%.
CONCLUSION
While the combination of HIFU and suction-curettage may induce common adverse effects such as lower abdominal or limb pain, these reactions typically do not necessitate therapeutic intervention. Additionally, the size of the gestational sac is a determinant of the procedure's success. In conclusion, HIFU combined with suction curettage demonstrates promising clinical efficacy, safety and favourable reproductive outcomes in managing CSP.
Topics: Humans; Female; Pregnancy; Blood Loss, Surgical; Vacuum Curettage; Cicatrix; Pain; Cesarean Section
PubMed: 38329796
DOI: 10.1080/02656736.2024.2310019 -
The American Journal of Sports Medicine Feb 2024Previous biomechanical studies have identified capsular closure, labral repair or reconstruction, and osteochondroplasty as important surgical interventions to improve...
BACKGROUND
Previous biomechanical studies have identified capsular closure, labral repair or reconstruction, and osteochondroplasty as important surgical interventions to improve hip stability.
PURPOSE
To investigate the outcome metrics used to quantify hip stability and assess and measure the relative contributions of the labrum, capsule, and bone to hip stability through a quantitative analysis.
STUDY DESIGN
Systematic review and meta-analysis; Level of evidence, 4.
METHODS
PubMed and Embase databases were searched using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies evaluated cadaveric hip biomechanics related to capsular, labral, and bony management during hip arthroscopy. Studies were assessed for distraction force and distance, fluid measures, and contact forces used to quantify the suction seal. Exclusion criteria included open surgery, arthroplasty, reorientation osteotomy, or traumatic dislocation.
RESULTS
A total of 33 biomechanical studies comprising 322 hips that evaluated 1 or more of the following were included: distraction force or distance (24 studies), fluid measures (10 studies), and contact forces (6 studies). Compared with a capsulotomy or capsulectomy, capsular repair or reconstruction demonstrated greater resistance to distraction (standardized mean difference [SMD], 1.13; 95% CI, 0.46-1.80; = .0009). Compared with a labral tear, a labral repair or reconstruction demonstrated less resistance to distraction (SMD, -0.67; 95% CI, -1.25 to -0.09; = .02). Compared with a labral debridement, repair or reconstruction demonstrated greater resistance to distraction (SMD, 1.74; 95% CI, 1.23 to 2.26; < .00001). No quantitative analysis was feasible from studies evaluating the effect of osseous resection due to the heterogeneity in methodology and outcome metrics assessed.
CONCLUSION
Most biomechanical evidence supports capsulotomy repair or reconstruction to improve hip distractive stability at the end of hip arthroscopic surgery. While the repair of a torn labrum does not improve distractive resistance, it is superior to labral debridement in most biomechanical studies.
PubMed: 38318815
DOI: 10.1177/03635465231208193 -
Surgical Endoscopy Feb 2024Postoperative pain is a common issue following laparoscopic cholecystectomy. This meta-analysis aimed to determine if active gas aspiration is more effective than... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Postoperative pain is a common issue following laparoscopic cholecystectomy. This meta-analysis aimed to determine if active gas aspiration is more effective than passive gas aspiration in reducing postoperative pain and analgesic requirements.
METHODOLOGY
The study conducted a systematic search of various databases, including Embase, Medline, and Cochrane Central Register of Controlled Trials (CENTRAL) via Ovid. It also searched trial registries and reference lists of included studies, with no date restrictions but limited to English language, up to December 21, 2022. The study included all randomized clinical trials that had documented elective laparoscopic cholecystectomy procedure and reported at least one relevant outcome. Articles that included subdiaphragmatic drain, intraperitoneal normal saline infusion, or pulmonary recruitment maneuver were excluded from the analysis. Two reviewers independently and in duplicate assessed the eligibility of studies and extracted data. The study reported findings according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The risk of bias of the included trials was assessed using the Revised Cochrane Risk of Bias Assessment Tool. The study used a random-effects model to pool data.
RESULTS
This meta-analysis included 5 randomized clinical trials with 367 participants and found that active gas aspiration resulted in significantly lower residual gas volume and total analgesia requirements compared to passive gas aspiration. Active gas aspiration also led to significantly lower shoulder pain scores at 24 h postoperatively. However, no significant differences were observed in hospital stay duration or abdominal pain scores.
CONCLUSION
The study found that active gas aspiration can be effective in reducing postoperative shoulder pain and analgesic requirements after laparoscopic cholecystectomy, which has important implications for patient care and healthcare costs. Importantly, this intervention does not impose any additional time or financial burden. However, further research is needed to evaluate its impact on other laparoscopic procedures.
Topics: Humans; Cholecystectomy, Laparoscopic; Shoulder Pain; Randomized Controlled Trials as Topic; Analgesics; Pain, Postoperative
PubMed: 38212468
DOI: 10.1007/s00464-023-10651-4 -
Interventional Neuroradiology : Journal... Dec 2023Although direct contact aspiration has emerged as one of the leading techniques for mechanical thrombectomy (MT), there is still ongoing debate about the... (Review)
Review
BACKGROUND
Although direct contact aspiration has emerged as one of the leading techniques for mechanical thrombectomy (MT), there is still ongoing debate about the aspiration/suction pump devices that can optimize recanalization rates. To address this gap, we conducted a meta-analysis comparing the aspiration efficacy of 60 ml syringe and pump devices in benchtop MT models.
METHODS
Systematic literature review was conducted using Medline, Embase, Web of Science, and Scopus in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Outcomes of interest included flow rate and vacuum pressure delivered by a 60 ml syringe and several aspiration pumps. We used a random effects model to calculate the mean difference (MD) with 95% confidence intervals (CIs) and a statistically significant difference was considered as a two-sided -value of less than 0.05.
RESULTS
We included six benchtop studies comparing 60 ml syringes and vacuum pumps. Our meta-analysis showed that there were no significant differences in vacuum pressure (MD:0.71inHg, 95% CI: [-0.81;2.23], = 0.359) and flow rate (MD:0.27 mL/s, 95% CI: [-3,07; 3.61], = 0.873) between 60 ml syringes and vacuum pumps groups.
CONCLUSIONS
Our study demonstrated comparable performance in terms of vacuum pressure and flow rates between a 60 ml syringe and a heterogeneous combination of commercially available aspiration pumps.
PubMed: 38151033
DOI: 10.1177/15910199231222305 -
Archivos de Bronconeumologia Feb 2024
Topics: Humans; Respiration, Artificial; Suction; Critical Illness; Intubation, Intratracheal; Critical Care
PubMed: 38044232
DOI: 10.1016/j.arbres.2023.11.010 -
Actas Urologicas Espanolas 2024High intrarenal pressure (IRP) is a potential risk factor for infectious complications related to URS. Methods to lower IRP have been described. However, it is still not... (Review)
Review
INTRODUCTION
High intrarenal pressure (IRP) is a potential risk factor for infectious complications related to URS. Methods to lower IRP have been described. However, it is still not possible to assess live IRP values during URS. The objective of this study was to perform a systematic review of the literature regarding endoscopic methods to measure IRP during URS.
METHODS
A systematic search and review of Medline, PubMed and Scopus was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta Analysis (PRISMA) checklist and a narrative synthesis of the study results was performed.
RESULTS
A total of 19 articles were included in the review. Four non invasive (i.e. endoscopic) methods to measure IRP were reported: ureteral catheter, sensor wire, pressure sensor proximal to an irrigation system and a novel ureteral access sheath that integrates suction, irrigation, and IRP measurement.
CONCLUSIONS
We provide here a comprehensive overview of the reported clinical measuring systems of IRP during URS. The ideal system has not been developed yet, but urologists will be able to measure IRP during their daily practice soon. The implications of having this type of data during surgery remains unknown. Systems that could integrate irrigation, suction, IRP and temperature seems to be ideal.
Topics: Inventions; Kidney; Pressure; Ureter; Ureteroscopy; Humans
PubMed: 37832846
DOI: 10.1016/j.acuroe.2023.10.007 -
Cureus Jul 2023Airway suctioning is routinely performed in the majority of care circumstances, including acute care, subacute care, home-based settings, and long-term care. Using an... (Review)
Review
Airway suctioning is routinely performed in the majority of care circumstances, including acute care, subacute care, home-based settings, and long-term care. Using an artificial airway to suction the patient allows for the mobilization and evacuation of secretions. When a patient can't independently remove all of the secretions from their respiratory tract, suction is used. This can occur when the body produces excessive secretion or it is not eliminated quickly enough, causing the respiratory system's upper and lower respiratory secretions to accumulate. Airway blockage and inadequate breathing may result from this. Ultimately, this leads to a shortage of oxygen and carbon dioxide from the air, both of which are necessary for ideal cellular activity. Artificial airway suctioning is one of the most crucial components of airway care and a core competency for medical professionals trying to ensure airway patency. Artificial airway suctioning is a standard treatment carried out every day globally and is frequently done in both outpatient and inpatient patients. Therefore, specialists must know the safest and most efficient ways to perform surgery and any potential side effects. In ventilated infants and children, the removal of obstructive secretions by endotracheal suctioning is frequently done. It is unknown how suctioning affects the mechanics of breathing. This study used a prospective observational clinical design to examine the immediate impact of airway resistance in endotracheal suctioning, tidal volume, and dynamic lung regulation in mechanically ventilated adult patients and mechanically ventilated pediatric patients. The preparation, process, and indications for intraoperative fusion treatment in various circumstances are covered in this systematic review.
PubMed: 37641766
DOI: 10.7759/cureus.42579 -
Endoscopy International Open Aug 2023Despite the widespread use of endoscopic ultrasound (EUS)-guided tissue acquisition, the choice of optimal suction technique remains a subject of debate. Multiple...
Despite the widespread use of endoscopic ultrasound (EUS)-guided tissue acquisition, the choice of optimal suction technique remains a subject of debate. Multiple studies have shown conflicting results with respect to the four suction techniques: Dry suction (DS), no suction (NS), stylet slow-pull (SSP) and wet suction (WS). Thus, the present network meta-analysis (NMA) was conducted to compare the diagnostic yields of above suction techniques during EUS-guided tissue acquisition. A comprehensive literature search from 2010 to March 2022 was done for randomized trials comparing the aspirated sample and diagnostic outcome with various suction techniques. Both pairwise and network meta-analyses were performed to analyze the outcomes: sample adequacy, moderate to high cellularity, gross bloodiness and diagnostic accuracy. A total of 16 studies (n=2048 patients) were included in the final NMA. WS was associated with a lower odd of gross bloodiness compared to DS (odds ratio 0.50, 95% confidence interval 0.24-0.97). There was no significant difference between the various suction methods with respect to sample adequacy, moderate to high cellularity and diagnostic accuracy. On meta-regression, to adjust for the effect of needle type, WS was comparable to DS in terms of bloodiness when adjusted for fine-needle aspiration needle. Surface under the cumulative ranking analysis ranked WS as the best modality for all the outcomes. The present NMA did not show superiority of any specific suction technique for EUS-guided tissue sampling with regard to sample quality or diagnostic accuracy, with low confidence in estimates.
PubMed: 37564335
DOI: 10.1055/a-2085-3674