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Laganà AS, Etrusco A, Haydamous J, Semaan S, Agrifoglio V, Chiantera V, Vitagliano A, Riemma G, D'Amato A, Montagna E. Efficacy of letrozole for the treatment of tubal ectopic pregnancy: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 299:322-328. [PMID: 38968783 DOI: 10.1016/j.ejogrb.2024.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/25/2024] [Accepted: 06/30/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Tubal ectopic pregnancy (EP) is a life-threatening condition, especially if undiagnosed or misdiagnosed, tipically in low income countries and/or where women have limited access to health care. The current management protocol of tubal EP consists of either surgical management, or medical management with methotrexate. Recent studies, while few, have suggested that letrozole, an aromatase inhibitor, may play a role in the medical treatment of tubal EP. OBJECTIVES To evaluate the effectiveness of letrozole alone in the medical treatment of tubal EP. SEARCH STRATEGY Electronic databases were searched until 31 December 2023. SELECTION CRITERIA Retrospective or prospective studies reporting the treatment of tubal EP with letrozole alone were considered eligible for inclusion. DATA COLLECTION AND ANALYSIS Pooled results were expressed as OR with 95 %CI. Heterogeneity was assessed using Higgins I2. Subgroup analysis was performed to compare outcomes according to time after intervention. Subgroup differences were checked through χ2 test. RESULTS A total of 152 patients were included. Seventy-nine patients (51.97 %) were treated with letrozole, 39 patients (16.54 %) with methotrexate, and 34 patients (31.49 %) underwent surgical treatment. Pooled data analysis supports the consistency of the effect of letrozole in reducing β-hCG over time at a comparable rate among studies, and that treatment with letrozole is superior to surgery and has the same efficacy as methotrexate. However, all the included studies were judged at high risk of bias in terms of study design, sample representativeness, and sampling technique. Furthermore, short and long term side effects were not reported in any of the included studies. CONCLUSIONS Letrozole is a promising alternative to methotrexate and surgical therapy in the treatment of tubal EP. Although this meta-analysis suggests efficacy and low hazard of the drug and encourages its application, the data available today remain extremely sparse, which weakens any claims that can be made, and is not sufficient to assert that letrozole is safe and effective in the treatment of EPs. There is an absolute need for randomized studies with accurate patient selection, fixed doses, large sample sizes, and reporting of short- and long-term side effects to refute or confirm this assumption.
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Affiliation(s)
- Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127 Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
| | - Andrea Etrusco
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127 Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
| | - Joe Haydamous
- Department of Obstetrics Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UT Health), 77030 Houston, United States
| | - Samar Semaan
- Department of Obstetrics Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UT Health), 77030 Houston, United States
| | - Vittorio Agrifoglio
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127 Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy; Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", 80131 Naples, Italy
| | - Amerigo Vitagliano
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari "Aldo Moro", Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Gaetano Riemma
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Van-vitelli", 80138 Naples, Italy
| | - Antonio D'Amato
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari "Aldo Moro", Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Erik Montagna
- Postgraduation Program in Health Sciences, Faculdade de Medicina do ABC/Centro Universitário FMABC, 09060-870 Santo André, Brazil
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Ramadan A, Etrusco A, D'Amato A, Laganà AS, Chiantera V, Zgheib C, Shoucair H, Alakrah W, Yared G, Sleiman Z. Evaluation of the benefit of indocyanine green as an educational and practical tool for ureteral identification in laparoscopic pelvic surgery: a cross-sectional study. MINIM INVASIV THER 2024:1-9. [PMID: 38995862 DOI: 10.1080/13645706.2024.2376837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 06/02/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND Indocyanine green (ICG) is a visible near-infrared fluorescent dye. Several studies have reported its benefit in identifying important anatomical structures, tissue vascularization, and sentinel lymph nodes in the case of tumors. Studies have shown that ICG is critical and safe in gynecologic surgeries. However, research on how ICG dye can help surgeons in laparoscopic surgeries correctly identify the course of the ureter has yet to be further investigated. METHOD This cross-sectional study enrolled 62 gynecology attending and resident surgeons who were asked to identify the course of the ureter on images of laparoscopic surgeries. The results were then compared with images in which ICG dye highlighted the course of the ureter. The purpose of this study was to detect the ability of surgical assistants and residents to adequately identify the course of the ureter in laparoscopic pelvic surgeries. RESULTS No statistically significant differences were found in terms of year of residency, years of experience, number of laparoscopic procedures attended, and correct identification of ureter course. ICG proved useful in identifying the correct ureteral trajectory. CONCLUSIONS ICG can be a valuable tool to improve the correct identification of ureters and improve surgical outcomes.
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Affiliation(s)
- Aya Ramadan
- Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Andrea Etrusco
- Unit of Obstetrics and Gynecology, 'Paolo Giaccone' Hospital, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Antonio D'Amato
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari 'Aldo Moro', Policlinico of Bari, Bari, Italy
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, 'Paolo Giaccone' Hospital, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
| | - Christelle Zgheib
- Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Hassan Shoucair
- Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Warda Alakrah
- Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Georges Yared
- Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Zaki Sleiman
- Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
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Etrusco A, Chiantera V, Serra P, Stabile G, Margioula-Siarkou C, Della Corte L, Giampaolino P, Török P, Baldini GM, Ghezzi F, D'Amato A, Laganà AS. Impact of surgery on reproductive outcomes in women with deep endometriosis and proven presurgical infertility: Facts and controversies. Best Pract Res Clin Obstet Gynaecol 2024:102524. [PMID: 38910100 DOI: 10.1016/j.bpobgyn.2024.102524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/09/2024] [Accepted: 06/18/2024] [Indexed: 06/25/2024]
Abstract
In women with proven infertility and deep endometriosis (DE), optimal management is controversial. To date, there is no clear evidence on the association between infertility and different stages of rASRM, nor is there clear guidance from leading scientific societies for surgical treatment of DE patients. A comprehensive literature search was conducted on the main databases for English-language trials describing the effectiveness of surgery for DE in patients with proven infertility; 16 studies were deemed eligible for inclusion in this systematic review (CRD42024498888). Quantitative analysis was not possible because of the heterogeneity of the data. A descriptive summary of the results according to location of pathology, surgical technique used, and whether assisted reproductive technology (ART) was needed or not was provided. A total of 947 infertile women were identified, 486 of whom became pregnant, with an average pregnancy rate of 51.3%. Our review suggests that surgery can be of valuable help in improving reproductive outcomes by improving the results of ART. It has not been possible to reach robust conclusions on the outcomes of surgery based on the location of DE because of the heterogeneity of evidence available to date. Overall, although some data encourage first-line surgical management, further investigation is needed to determine its effective application before or after ART failure.
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Affiliation(s)
- Andrea Etrusco
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127, Palermo, Italy.
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127, Palermo, Italy; Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", 80131, Naples, Italy.
| | - Pietro Serra
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127, Palermo, Italy.
| | - Guglielmo Stabile
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71122, Foggia, Italy.
| | - Chrysoula Margioula-Siarkou
- 2(nd)Academic Department of Obstetrics and Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, 54643, Thessaloníki, Greece.
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80126, Naples, Italy.
| | - Pierluigi Giampaolino
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80126, Naples, Italy.
| | - Péter Török
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, 4032, Debrecen, Hungary.
| | | | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, 21100, Varese, Italy.
| | - Antonio D'Amato
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari "Aldo Moro", Policlinico of Bari, Piazza Giulio Cesare 11, 70124, Bari, Italy.
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127, Palermo, Italy.
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Maheta BJ, Manhas P, Niu A, Ong L, Ramsamooj A, Karashchuk I, Whang P, Puglisi J, Frezza EE. What Should I Use? Impact of Adhesion Barriers on Postoperative Abdominal Complications: A Systematic Review. Am Surg 2024:31348241258718. [PMID: 38795014 DOI: 10.1177/00031348241258718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2024]
Abstract
BACKGROUND Adhesions are a feared complication of abdominal surgery. There have been many new adhesion barriers developed and tested; however, there is no recent systematic review analyzing all the published literature. To address this, we aimed to analyze the different types of adhesion barriers, and determine their effects on postoperative outcomes in patients. METHODS A total of 14,038 articles utilizing adhesion barriers in abdominal surgery were retrieved from the PubMed, EMBASE, and Scopus databases. Inclusion criteria were: patients undergoing abdominal surgery, patients receiving an adhesion barrier, and reported postoperative outcomes. Two reviewers independently screened titles/abstracts and full-text articles using Covidence. The ROBINS-I tool was used to assess the quality of the included studies. Study protocol: Prospero CRD42023458230. RESULTS A total of 20 studies, with no overall high risk of bias, with 171,792 patients were included. Most studies showed an equivocal benefit for adhesion barriers, with no singular adhesion barrier type that had definitive superior outcomes compared to the others. Bioresorbable barriers emerged as the most extensively researched adhesion barrier type, exhibiting promising results in colorectal surgery. Starch-based adhesion barriers also exhibited a reduction in overall postoperative bowel obstructions and may be beneficial for stoma sites and port closures. On the other hand, many studies raised concerns regarding complications, including risk of abscess formation, fistula development, peritonitis, and anastomotic leakage. CONCLUSIONS Adhesion barriers should be considered on a case-by-case basis, however, they should not be utilized prophylactically in all abdominal surgeries due to their risk of complications.
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Affiliation(s)
- Bhagvat J Maheta
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Priya Manhas
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Ashley Niu
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Lauren Ong
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Anya Ramsamooj
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Irina Karashchuk
- Department of Surgery, Sutter Roseville Medical Center, Roseville, CA, USA
| | - Peter Whang
- Department of Surgery, Sutter Roseville Medical Center, Roseville, CA, USA
| | - Joseph Puglisi
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Eldo E Frezza
- California Northstate University College of Medicine, Elk Grove, CA, USA
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Wu T, Fang T, Dong Y, Mao J, Wang J, Zhao M, Wu R. Comparison of Secondary Prevention Following Hysteroscopic Adhesiolysis in the Improvement of Reproductive Outcomes: A Retrospective Cohort Study. J Clin Med 2023; 13:73. [PMID: 38202080 PMCID: PMC10779651 DOI: 10.3390/jcm13010073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/08/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
Intrauterine adhesion (IUA) is primarily caused by endometrial injury, and hysteroscopic adhesiolysis is presently the main treatment. However, postoperative recurrence and poor pregnancy outcomes remain intractable. In this study, we aim to assess the effects of different treatments on clinical symptoms and reproductive outcomes in IUA. This retrospective study was conducted in a tertiary university-affiliated women's hospital. The study included 1449 consecutive women who desired to have a baby and were diagnosed with IUA through hysteroscopy from January 2016 to December 2021. Patients with IUA underwent hysteroscopic electric resection (E) or cold scissors separation (C), as well as hormone therapy and one or both of the following secondary prevention measures: intrauterine devices (IUD) and hyaluronic acid gel (HA). The pregnancy rate (PR) was significantly higher in the E + IUD + HA (90.23% CI: 85.82, 94.64%) than in other groups (p = 0.000) groups. The rates of full-term birth (p = 0.000) and live birth (p = 0.000) were significantly higher in the E + IUD + HA (67.82% and 68.97%, respectively) and E + HA (62.41% and 63.91%, respectively) groups. Multivariate logistic regression analysis revealed a significantly higher PR in women who received second-look hysteroscopy (OR 1.571, 95% CI: 1.009-2.224, p = 0.013) and E + IUD + HA (OR 4.772, 95% CI: 2.534-8.987, p = 0.000). Combining hysteroscopic electric resection with IUDs and HA gel could prevent adhesion recurrence and improve postoperative pregnancy and live birth outcomes in IUA. Furthermore, postoperative second-look hysteroscopy may increase the PR and shorten the waiting period.
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Affiliation(s)
| | | | | | | | | | | | - Ruijin Wu
- Department of Gynecology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
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