Meta-analysis on the use of hyaluronic acid gel to prevent recurrence of intrauterine adhesion after hysteroscopic adhesiolysis

Intrauterine adhesion is a severe complication after intrauterine operation, Various adjuvant therapies failed to improve clinical symptoms and pregnancy rates among patients with moderate-to-severe intrauterine adhesion. At present, hyaluronic acid gel is widely used in the primary prevention of adhesion after hysteroscopic adhesiolysis. However, its efficacy is still under debate. Therefore, the aim of this study was to systematically evaluate the efficacy of hyaluronic acid gel in preventing the recurrence of intrauterine adhesion after hysteroscopic adhesiolysis. The Cochrane Library, Embase, and PubMed databases were used to search for articles published before July 31, 2018, using the following terms: hyaluronic acid, intrauterine adhesions, Asherman's syndrome, IUA, hysteroscopy, and hysteroscopic adhesiolysis. Studies on therapies after hysteroscopic adhesiolysis were collected. The recurrence rate of and pregnancy rate in the presence of intrauterine adhesion after hysteroscopic adhesiolysis were analyzed by RevMan 5.3 software. A total of 6 articles were selected, which included 394 patients who were subjected to hysteroscopic adhesiolysis. The meta-analysis results showed that (1) no statistically significant difference was found between hyaluronic acid gel use and without its use on the score of intrauterine adhesion after hysteroscopic adhesiolysis [the mean difference (MD) = ?0.89, 95% confidence interval (CI) (?2.53–0.76), P = 0.29], neither a statistically significant difference was observed between the same groups on the recurrence rate of intrauterine adhesion [odds ratio (OR) = 0.75, 95% CI (0.31–1.81), P = 0.53]; (2) subgroup analysis showed that hyaluronic acid gel could reduce the rate of intrauterine adhesion recurrence in randomized controlled trials [OR = ?0.28, 95% CI (0.14–0.56), P = 0.0006]. However, the recurrence rate of intrauterine adhesion after the use of hyaluronic acid gel was not statistically significant in non-randomized controlled experiments [OR = 1.53, 95% CI (0.79–2.95), P = 0.21]; (3) hyaluronic acid gel did not result in a significant effect on pregnancy rate after intrauterine adhesion separation [OR = 2.02, 95% CI (0.53–7.66), P = 0.3]. In conclusion, hyaluronic acid gel could reduce the recurrence rate of intrauterine adhesion, but had no significant effect on the postoperative pregnancy rate.     

子宫腔整复手术后再粘连的防治

宫腔粘连是子宫内膜基底层损伤所引起的疾病，严重影响女性生理健康和生育功能。宫腔镜下宫腔粘连分离术作为子宫腔整复手术的首选治疗方法，以恢复子宫正常解剖结构及功能为目的，但术后复发仍是妇科医生面临的巨大挑战。目前防治术后再粘连的方法主要有屏障治疗、激素治疗和羊膜疗法等，其他的治疗选择，如干细胞疗法、阿司匹林、富血小板血浆、西地那非等治疗尚处于研究当中。目前尚无防治术后再粘连的最佳治疗方案，如何达到最佳治疗效果仍需进一步研究。     

硬膜外腔导管松解治疗腰椎间盘突出症

[目的]探讨硬膜外腔导管松解、精确药物注射,治疗腰椎间盘突出症所致腰腿痛的临床疗效。[方法]2009年1月～2010年10月,收治腰椎间盘突出症患者88例,男48例,女40例;年龄25～72岁,平均(40.76±10.59)岁。所有患者分成两个治疗组,各44例。对照组(骶管组)采用单纯骶管注射治疗;观察组(导管组)采用经皮、经骶管入路,行硬膜外腔导管松解、精确药物注射。采用Oswestry功能障碍指数(oswestry disability index,ODI)、疼痛视觉模拟评分(visual analogue scale,VAS)评估患者术后疗效。[结果]88例均获得25～36个月的随访,平均(29.3±4.0)个月。对照组:ODI术前平均为(68.3±13.2)%,末次随访平均为(41.2±21.1)%;VAS评分术前平均为(6.6±1.2)分,末次随访平均为(3.9±2.1)分。观察组:ODI术前平均为(70.5±13.6)%,末次随访平均为(23.3±18.6)%;VAS评分术前平均为(6.7±1.2)分,末次随访平均为(2.1±1.6)分。末次随访时,两组Oswestry功能障碍指数(ODI)改善率差异具有统计学意义(P<0.05)。[结论]经皮、经骶管行硬膜外腔导管松解、精确药物注射,是可有效缓解腰椎间盘突出症所致腰腿痛症状的微创治疗方式。     

Epiduroscopy for Patients With Lumbosacral Radicular Pain

Lumbosacral radicular pain is a pain in the distribution area of one of the nerves of the lumbosacral plexus, with or without sensory and/or motor impairment. A major source of lumbosacral radicular pain is failed back surgery, which is defined as persistent or recurrent pain, mainly in the region of the lower back and legs even after technically, anatomically successful spine surgeries. If lumbosacral radicular neuropathic pain fails to respond to conservative or interventional treatments, epiduroscopy can be performed as part of a multidisciplinary approach. Epiduroscopy aids in identifying painful structures in the epidural space, establishing a diagnosis and administering therapy. The novelty consists in the use of an epiduroscope to deliver therapies such as adhesiolysis and targeted administration of epidural medications. Clinical trials report favorable treatment outcomes in 30% to 50% of patients. Complications are rare and related to the rate or volume of epidural fluid infusion or inadvertent dural puncture. In patients with lumbosacral radicular pain, especially after back surgery, epiduroscopy with adhesiolysis may be considered (evidence rating 2 B+).     

Microsurgical adhesiolysis: a comparative study of the CO2-laser and the microelectrode in experimental animals

After traumatizing the serosa in 60 white rats, the induced adhesions were dissolved 14 days later using a CO₂-laser or a microelectrode under microscopic conditions. A third laparotomy was performed 14 days thereafter to evaluate the postoperative results. Microsurgical adhesiolysis was satisfactory in 22 of 42 rats with severe adhesions. When both methods were compared, the CO₂-laser results (14 out of 21) were superior to those of the microelectrode (8 out of 21).     

An analysis of the outcome of microsurgical and laparoscopic adhesiolysis for infertility

We evaluated 81 women with adnexal adhesions and no male factorwho underwent microsurgical (n = 59) and laparoscopic (n = 22)adhesiolysis for infertility. The cumulative conception ratesfor all 81 patients at 12 and 24 months were 41 and 44% respectively.The impact of the following variables on cumulative conceptionrates for all patients was examined: age, duration of infertility,type of infertility, ovulatory status, presence and stage ofendometriosis, adhesion grade, adnexal status (bilateral orunilateral disease, unilateral tubal absence), history of previoussurgery, history of pelvic inflammatory disease and treatmentmodality (microsurgical versus laparoscopic). The results ofindependent comparisons of subgroups within each of these variablesmay be biased because of the interrelationships between thevariables. To overcome this problem, a stepwise Cox's proportionalhazards regression analysis was employed. Our analysis showedthat the single most significant variable influencing the cumulativeconception rates was the duration of infertility (P < 0.005).For every additional year of infertility, the probability ofpregnancy after adhesiolysis (microsurgical or laparoscopic)was reduced by 20%. Cumulative conception rates at 12 and 24months after microsurgical adhesiolysis were 36 and 40% respectively,while after laparoscopic adhesiolysis they were 57% at 12 and24 months. When imbalances were adjusted between the two treatmentgroups, there was no statistically significant difference betweenthe cumulative conception rates for microsurgical and laparoscopicadhesiolysis.     

Laparoscopic approach to postoperative adhesive obstruction

Background Some authors have assessed the feasibility of laparoscopy in the treatment of postoperative adhesive obstruction, but conclusions about its effectiveness are related to different selection criteria used for surgery. This paper reports on our experience in laparoscopic adhesiolysis and analyses the results on the basis of the selection criteria used.Methods From January 1993 to December 2001, 65 patients were submitted to laparoscopic adhesiolysis for small bowel obstruction according to specific selection criteria. Of the 65 patients, 40 were admitted for acute obstruction and 25 for chronic or recurrent transit disturbances. Correlation between historical and clinical data and the results of surgical treatment were statistically analyzed.Results The procedure was completed by laparoscopy in 52 patients (conversion rate: 20%). Mean postoperative stay was 4.4 days with a 12.3% morbidity and no mortality. Recurrence rate was 15.4%; a single correlation was found between recurrence and age.Conclusions Laparoscopic adhesiolysis in the treatment of small bowel obstructions seems to be effective; further studies are required to define selection criteria for surgery and confirm real advantages in terms of recurrences.