A novel intrauterine estrogen-releasing system for preventing the postoperative recurrence of intrauterine adhesion: a multicenter randomized controlled study.

BACKGROUND: Transcervical resection of adhesions (TCRA) is the standard treatment for intrauterine adhesion (IUA). Previous studies have shown that postoperative oral estrogen or an intrauterine physical barrier could reduce the recurrence of IUA by promoting the proliferation of the endometrium or inhibiting the reformation of adhesions. Our team designed an intrauterine stent that can release estrogen within the uterine cavity slowly. In this study, we aimed to investigate the efficacy and safety of the estrogen-releasing intrauterine system in preventing the recurrence of moderate to severe IUA. METHODS: This was a multicenter prospective randomized controlled 2-arm parallel trial that included patients who were diagnosed with moderate to severe IUA and who received TCRA. A total of 250 patients were randomly assigned, at a 1:1 ratio, to receive the intrauterine estrogen-releasing system or a Foley catheter balloon combined with oral estrogen therapy after surgery. The primary outcome was the rate of adhesion reduction in the two groups. The secondary outcomes included endometrial thickness at the ovulation period, menstrual improvement rates, and other reported adverse events during follow-up. RESULTS: The average daily drug release amount for all the tested stents was 0.21 mg/day. At 60 days postoperatively, the rate of adhesion reduction was significantly greater in the experimental group than in the control group (93.33% vs. 58.56%, p < 0.001). The endometrium of the experimental group was thicker than that of the control group (p < 0.001). Consistently, the rate of improvement in menstruation was greater in the experimental group than in the control group (p = 0.010). No grade 3-4 adverse events were found in the two groups during the 1-year follow-up. CONCLUSIONS: In the cohort of patients with moderate to severe IUA, the intrauterine estrogen-releasing system was more effective at reducing adhesion than traditional oral estrogen combined with an intrauterine Foley catheter after TCRA. This novel intrauterine system provides a new option for the management of IUA after surgery. TRIAL REGISTRATION: The registration number is NCT04972032. Date of registration: August 15, 2021.

Impact of head and neck radiation on long-term outcomes after carotid revascularization.

OBJECTIVE: Radiation-induced carotid artery stenosis (RICS) is a well-described phenomenon seen after head and neck cancer radiation. Previously published literature suggests that, compared with atherosclerotic disease, RICS may result in worse long-term outcomes and early restenosis. This study aims to evaluate the effect of radiation on long-term outcomes after various carotid revascularization techniques using a multi-center registry database. METHODS: Patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) registry for carotid artery intervention (carotid endarterectomy [CEA]; transfemoral carotid artery stenting [CAS]; transcarotid artery revascularization [TCAR]), who are 65 years or older were included in the study. VQI Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Medicare-linked database was used to obtain long-term procedure-specific outcomes. Primary endpoints were 3-year death, stroke, and reintervention. We performed propensity matching between patients with prior radiation and those without. Kaplan-Meier analysis and a multivariate logistic regression model were used to analyze the outcome variables. RESULTS: A total of 56,472 patients had undergone carotid revascularization (CEA, n = 48,307; TCAR, n = 4593; CAS, n = 3572), 1244 patients with prior radiation and 54,925 patients without prior radiation. The prior radiation group was more likely to be male (71.9% vs 60.3%; P < .01), to receive a stent (47.5% vs 13.5%; P < .01), and to be on P2Y12 inhibitor (55.2% vs 38.3%; P < .01). Propensity matching was performed on 1223 patients (CEA, n = 655; TCAR, n = 292; CAS, n = 287). There were no significant differences in 30-day outcomes for death, stroke, or major adverse cardiovascular events for all three procedures. The prior radiation group had higher rates of cranial nerve injury (3.7% vs 1.8%; P = .04) and 90-day readmission (23.5% vs 18.3%; P = .01) after CEA. For long-term outcomes, prior radiation significantly increased mortality risk for CEA and CAS (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.38-2.27 and HR, 1.56; 95% CI, 1.02-2.36, respectively). The 3-year risk of stroke for CEA in radiated patients was also significantly higher (HR, 1.47; 95% CI, 1.03-2.09) compared with non-radiated patients. Prior radiation did not significantly affect death and stroke in patients undergoing TCAR. Prior radiation also did not impact the rates of short and long-term reintervention after CEA, CAS, or TCAR. CONCLUSIONS: Prior head and neck radiation significantly increases the risk for mortality and stroke for CEA and the risk for mortality after CAS. Long-term outcomes for TCAR are not significantly affected by prior radiation. TCAR may be the preferred treatment modality for patients with radiation-induced carotid stenosis.

Surveillance and risk factors for early restenosis following transcarotid artery revascularization.

OBJECTIVE: Restenosis after transcarotid artery revascularization (TCAR) is a known complication. When identified in the early postoperative period, it may be related to technique. We evaluated our TCAR experience to identify potentially modifiable factors impacting restenosis. METHODS: This is a single-institution, retrospective review of patients undergoing TCAR from November 2017 to July 2022. Restenosis was defined as >50% stenosis on duplex ultrasound (DUS) examination or computed tomographic angiography (CTA). Continuous variables were compared using Kruskal-Wallis's test. Categorical variables were compared using the Fisher's exact test. RESULTS: Of 61 interventions, 11 (18%) developed restenosis within the median follow-up of 345 days (interquartile range, 103-623 days). Among these patients, 82% (9/11) had >50% stenosis, and 18% (2/11) had >80% stenosis. Both patients with high-grade restenosis were symptomatic and underwent revascularization. Diagnosis of post-TCAR restenosis was via DUS examination in 45% (5/11), CTA in 18% (2/11), or both CTA/DUS examination in 36% (4/11). Restenosis occurred within 1 month in 54% (6/11) and 6 months in 72% (8/11) of patients. However, three of the six patients with restenosis within 1 month had discordant findings on CTA vs DUS imaging. Patient comorbidities, degree of preoperative stenosis, medical management, balloon size, stent size, lesion characteristics, and predilatation angioplasty did not differ. Patients with restenosis were younger (P = .02), had prior ipsilateral endarterectomy (odds ratio [OR], 6.5; P = .02), had history of neck radiation (OR, 18.3; P = .01), and lower rate of postdilatation angioplasty (OR, 0.11; P = .04), without an increased risk of neurological events. CONCLUSIONS: Although post-TCAR restenosis occurred in 18% of patients, only 3% of patients had critical restenosis and required reintervention. Patient factors associated with restenosis were younger age, prior endarterectomy, and history of neck radiation. Although early restenosis may be mitigated by improved technique, the only technical factor associated with restenosis was less use of postdilatation angioplasty. Balancing neurological risk, this factor may have increased application in appropriate patients. Diagnosis of restenosis was inconsistent between imaging modalities; current surveillance paradigms and diagnostic thresholds may warrant reconsideration.

Bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy compared with thoracolaparoscopic esophagectomy for esophageal cancer: a propensity score-matched analysis.

BACKGROUND: Transcervical mediastinoscopic esophagectomy for esophageal and esophagogastric junction cancer is indicated in select institutions because of the complex surgical technique required and the unfamiliar surgical view compared with the standard transthoracic esophagectomy approach. This study was performed to compare the feasibility and efficacy of bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy (BTC-MATLE) with thoracolaparoscopic esophagectomy (TLE) for esophageal cancer. METHODS: This study involved 392 consecutive patients with esophageal cancer who underwent curative minimally invasive esophagectomy with R0 resection (excluding salvage, conversion, and two-stage operations and open thoracotomy) at the National Cancer Center Hospital from 2017 to 2022. The patients underwent either BTC-MATLE or TE (32 and 360 consecutive patients, respectively). Propensity score-matching analysis was used to balance the baseline differences by covariates of age, performance status, and clinical stage. RESULTS: There were statistically significant differences in age, performance status, cT factor, cN factor, cStage, preoperative treatment, and surgical history for respiratory disease. After propensity score-matching, these significant differences (excluding a surgical history of respiratory disease) were no longer statistically significant, and 27 patients were assigned to each group. The total operation time and the postoperative intensive care unit stay were significantly shorter in the BTC-MATLE than TLE group. There were no significant differences in overall postoperative complications or the three major postoperative complications of recurrent laryngeal nerve paralysis, anastomotic leakage, and pneumonia, even for patients whose preoperative pulmonary function indices (vital capacity and forced expiratory volume in 1 s) were significantly lower in the BTC-MATLE than TLE group. The numbers of total and thoracic harvested lymph nodes were significantly higher in the TLE than BTC-MATLE group; however, there was no significant difference in the recurrence rate between the two groups. CONCLUSION: BTC-MATLE may provide the same feasibility and oncological outcomes as TLE even for patients with significantly lower pulmonary function.

Robot-assisted transcervical esophagectomy with a bilateral cervical approach for thoracic esophagectomy.

BACKGROUND: Thoracic esophageal cancer resection through the neck approach has recently been reported as mediastinoscopic surgery. We present the first report of a new minimally invasive technique for thoracic esophageal cancer: robot-assisted transcervical esophagectomy with a bilateral cervical approach. METHODS: Ten cases of robot-assisted bilateral transcervical esophagectomy performed at the National Cancer Center Hospital East, Japan, from February 2023 to August 2023 were reviewed. The short-term surgical outcomes were presented, and the feasibility and efficacy of this procedure were discussed. RESULTS: The mean operation time for the cervical procedure was 184.2 ± 23.6 min. The total time for the whole procedure was 472.7 ± 28.4 min, and total intraoperative blood loss was 162.2 ± 40.0 ml. Among the 10 cases, one patient developed recurrent nerve paralysis, one patient developed pulmonary complications, and no patients developed postoperative pneumonia. The median postoperative hospital stay was 22 (range: 12-43) days. No patients developed severe postoperative surgical complications, which were graded as Clavien-Dindo ≥ III. The total number of surgically harvested mediastinal lymph nodes was 37.2 ± 11.2. CONCLUSIONS: Robot-assisted bilateral transcervical esophagectomy, a novel procedure for thoracic esophageal cancer, was safe and feasible. Using this procedure, the incidence of recurrent nerve palsy, which is a problem with transcervical esophagectomy and mediastinoscopic esophagectomy, is expected to decrease.

Chronic endometritis multiplies the recurrence risk of endometrial polyps after transcervical resection of endometrial polyps: a prospective study.

BACKGROUND: To investigate the impact of chronic endometritis (CE) on the recurrence of endometrial polyps (EPs) in premenopausal women after transcervical resection of endometrial polyps (TCRP). METHODS: This prospective study enrolled 507 women who underwent TCRP between January 1, 2022 and December 31, 2022. The patients were divided into a CE group (n = 133) and non-CE group (n = 374) based on the expression of CD138 in the endometrium. The EP recurrence rate at 1 year after TCRP was compared between the CE and non-CE groups and between groups with mild CE and severe CE. The impact of CD138 expression by resected EPs on EP recurrence also was investigated. RESULTS: The EP recurrence rate at 1 year post-TCRP was higher in the CE group than in the non-CE group (25.6% vs. 10.4%) and also higher in the severe CE group than in the mild CE group (34.5% vs. 18.7%). Additionally, the EP recurrence rate was higher among patients with CD138-expressing EPs than among those with EPs lacking CD138 expression (30.5% vs. 6.5%). The odds ratio (OR) for EP recurrence in the CE cohort compared with the non-CE cohort was 3.10 (95% confidence interval [CI] 1.84-5.23) after adjustment for EP number and precautions against EP recurrence. The ORs for EP recurrence in patients with mild CE and severe CE were 2.21 (95%CI 1.11-4.40) and 4.32 (95%CI 2.26-8.26), respectively. Similarly, the OR for EP recurrence in cases with CD138-expressing EPs relative to cases with EPs lacking CD138 expression was 6.22 (95%CI 3.59-10.80) after adjustment for EP number and precautions against EP recurrence. CONCLUSIONS: CE multiplied the recurrence rate of EPs in premenopausal women after TCRP, and this effect positively correlated with CE severity. CD138 expression by EPs also was associated with a higher risk for EP recurrence.

Metabolic acidemia due to saline absorption during transurethral and transcervical surgery: a report of 2 cases.

BACKGROUND: The development of endoscopic systems that include bipolar electrocautery has enabled the use of normal saline irrigation in transurethral or transcervical endoscopic surgery. However, excessive saline absorption can cause hyperchloremic metabolic acidosis. CASE PRESENTATION: Patient 1: A 76-year-old man was scheduled for transurethral resection of the prostate with saline irrigation. Approximately 140 min after the surgery, abdominal distension and cervical edema were observed. Abdominal ultrasound examination indicated a subhepatic hypoechoic lesion, which suggested extravasation of saline. Arterial blood gas analysis revealed hyperchloremic metabolic acidosis. The patient was extubated 2 h after the operation with no subsequent airway problems, and the electrolyte imbalance was gradually corrected. Patient 2: A 43-year-old woman was scheduled for transcervical resection of a uterine fibroid with saline irrigation. When the drape was removed after the operation was finished, notable upper extremity edema was observed. Arterial blood gas analysis revealed hyperchloremic metabolic acidosis. The patient's acidemia, electrolyte imbalance, and neck edema gradually resolved, and the patient was extubated 16 h after the operation without subsequent airway problems. CONCLUSIONS: Anesthesiologists should be aware of acidemia, cardiopulmonary complications, and airway obstruction caused by excessive saline absorption after saline irrigation in endoscopic surgery.

Locoregional Versus General Anesthesia for Carotid Artery Stenting in the American College of Surgeons National Surgical Quality Improvement Project.

OBJECTIVES: Carotid artery stenting (CAS) may be performed by transfemoral or transcervical (TCAR) approaches and with a variety of anesthetic techniques. No current literature clearly supports one anesthetic method over another. We therefore sought to evaluate the outcomes of CAS procedures based on anesthetic approach. DESIGN: Retrospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2018. PARTICIPANTS: All individuals undergoing CAS during the study period. INTERVENTIONS: Anesthetic type (locoregional versus general [GA]). MEASUREMENTS AND MAIN RESULTS: Locoregional anesthesia for CAS was used for 754 (65.5%) patients, with the remainder under GA. Demographic variables were comparable, as were the incidence of symptomatic presentation, high-risk anatomy or physiology, severity of the stenosis, and presence/severity of contralateral carotid disease. There was no difference in composite outcome (stroke, myocardial infarction [MI], and death) (7.0% v 6.1%, p = 0.53). The GA group had lower odds ratio of MI (0.12, p = 0.0362) but higher odds ratio of death (3.33, p = 0.008) and postoperative pneumonia (3.87, p = 0.0083), although on multivariable analysis the risk of death appeared confounded by respiratory variables. Multivariable and propensity score-weighted analyses did not identify a significant association of GA with the composite outcome. CONCLUSIONS: In patients undergoing CAS in the National Surgical Quality Improvement Program, GA was not associated with the composite outcome but was associated with increased rates of postoperative pneumonia and decreased rates of MI. Further investigation should attempt to better clarify these relationships.

The association between maternal colonization with Group B Streptococcus and infectious morbidity following transcervical Foley catheter-assisted labor induction.

OBJECTIVES: To determine whether maternal colonization with Group B Streptococcus increases the risk for infectious morbidity following transcervical Foley catheter-assisted cervical ripening. METHODS: A retrospective cohort study comparing infectious morbidity and other clinical outcomes by Group B Streptococcus colonization status between all women with singleton pregnancies who underwent Foley catheter-assisted cervical ripening labor induction at a single tertiary medical center during 2011-2021. Multivariable logistic regression explored the relationship between Group B Streptococcus colonization to adverse outcomes while adjusting for relevant clinical variables. RESULTS: A total of 4,409 women were included of whom 886 (20.1 %) were considered Group B Streptococcus carriers and 3,523 (79.9 %) were not. Suspected neonatal sepsis rate was similar between Group B Streptococcus carriers and non-carriers (5.2 vs. 5.0 %, respectively, p=0.78). Neonatal sepsis was confirmed in 7 (0.02 %) cases, all born to non-carriers. Group B Streptococcus carriers had a higher rate of maternal bacteremia compared to non-carriers (1.2 vs. 0.5 %, respectively, p=0.01). Group B Streptococcus colonization was independently associated with maternal bacteremia (adjusted odds ratio 3.05; 95 %CI 1.39, 6.66). CONCLUSIONS: Group B Streptococcus colonization among women undergoing Foley catheter-assisted cervical ripening does not seem to increase the risk for neonatal infection. However, higher rates of maternal bacteremia were detected.

Direct embryonic biopsy with transcervical embryoscopy is an effective method for karyotyping and morphology assessment in miscarriages.

PURPOSE: The main purpose of this study is to compare the validity of transcervical embryoscopy method with standard uterine evacuation method in detecting more accurate karyotypes in miscarriages below tenth week of pregnancy. Additionally, the frequency and distribution of fetal morphological abnormality were evaluated. METHODS: A prospective study was carried out at the Gazi University Faculty of Medicine, Department of Obstetrics and Gynecology. Patients with missed abortions between sixth and tenth gestational weeks were included in the study group, and fetal morphological examination and direct embryonic biopsy were performed by transcervical embryoscopy. The control group consisted of patients who experienced miscarriage and genetic material obtained from routine uterine evacuation between February and October 2023. RESULT: A total of 60 patients in the study group and 189 patients in the control group were evaluated. The median ages, previous miscarriage numbers, median gravida numbers, and median gestational weeks were comparable between groups. Chromosomal abnormality was detected in 24 (42.8%) and 52 embryos (29.9%) in the study and control groups, respectively (p = 0.004). Culture failure rates were 6.6% (n = 4) and 7.9% (n = 15) in the study and control groups, respectively. In the study group, 12 embryos had a morphological abnormality in which 6 of them had normal karyotype. CONCLUSION: Direct embryonic biopsy with transcervical embryoscopy is an effective method to exclude maternal decidual cell contamination and placental mosaicism in miscarriages for karyotype analysis. In addition, detecting anomalies in morphology might contribute our understanding in the process of miscarriages which arises independent from structural/numerical chromosomal abnormalities.

Predicting failure of detection of peritonsillar abscess with ultrasound in pediatric populations.

PURPOSE: Some patients require additional imaging following ultrasound (US) to definitively diagnose a peritonsillar abscess (PTA), delaying intervention and disease resolution. We seek to evaluate patient characteristics which may predispose to a secondary imaging requirement to diagnose PTA, in order to better understand ultrasound limitations and predict who will require additional studies. MATERIALS AND METHODS: Retrospective chart review of patients with an US for suspected PTA between July 2017 and July 2020. Patient age, weight, and clinical characteristics, such as pain, trismus, and reduced neck range of motion (ROM) were collected. The need for additional imaging, subsequent surgical intervention, and hospital length of stay (LOS) were also recorded. RESULTS: Of 411 qualifying patients, 73 underwent additional imaging. Patients who required additional imaging were younger (9.8 vs 11.3 years, p = 0.026) and more likely to have decreased neck ROM (17.8 vs 5.3 %, p = 0.001). Surgical intervention was performed more commonly (27.4 vs 14.8 %, p = 0.015) and hospital LOS was longer (24.0 vs 5.0 h, p < 0.001) in those with secondary imaging. CONCLUSIONS: Specific patient characteristics, such as younger age and decreased neck range of motion, are associated with a higher need for additional imaging. Additionally, the need for additional imaging is associated with a longer hospital LOS and increased likelihood of surgical intervention. Nearly 18 % of patients who underwent US evaluation of PTA required secondary imaging. Although transcervical US remains an excellent tool for diagnosing PTA, this data supports the utility of secondary imaging in certain instances.

Periprocedural P2Y12 inhibitors improve perioperative outcomes after carotid stenting by primarily decreasing strokes.

OBJECTIVE: The continuation of antiplatelet agents in the periprocedural period around carotid stenting (CAS) procedures is felt to be mandatory to minimize the risk of periprocedural stroke. However, the optimal antiplatelet regimen is unclear, with some advocating dual antiplatelet therapy, and others supporting the use of P2Y12 inhibitors alone. The objective of this study was to evaluate the periprocedural effect of P2Y12 inhibitors for CAS. METHODS: The Vascular Quality Initiative was used from years 2007 to 2020. All transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) procedures were included. Patients were stratified based on perioperative use of P2Y12 inhibitors as well as symptomatic status. Primary end points were perioperative neurological events (strokes and transient ischemic attacks). Secondary end points were mortality and myocardial infarction. RESULTS: A total of 31,036 CAS procedures were included for analysis, with 49.8% TCAR and 50.2% TF-CAS cases; 63.8% of patients were male and 82.3% of patients were on a P2Y12 inhibitor. P2Y12 inhibitor use was more common in males, asymptomatic patients, those older than 70 years, and concurrent statin use. P2Y12 inhibitors were more likely to be used in TCAR cases than in TF-CAS cases (87.3% vs 76.8%; P < .001). The rate of periprocedural neurological events in the whole cohort was 2.6%. Patients on P2Y12 inhibitors were significantly less likely to experience a periprocedural neurological event (2.3% vs 3.9%; P < .001) and mortality (0.6% vs 2.1%; P < .001) than those who were not on a P2Y12 inhibitor. There was no effect on the rates of myocardial infarction. On multivariate analysis, both symptomatic and asymptomatic patients on P2Y12 inhibitors were significantly less likely to develop perioperative neurological events. Additionally, the use of P2Y12 inhibitors demonstrated an independent significant effect in reducing of the rate of perioperative stroke (odds ratio, 0.29; 95% confidence interval, 0.25-0.33). Finally, additional analysis of the types of P2Y12 inhibitors used revealed that all seemed to be equally effective in decreasing the periprocedural neurological event rate. CONCLUSIONS: The use of perioperative P2Y12 inhibitors seems to markedly decrease the perioperative neurological event rate with TCAR and TF-CAS in both symptomatic and asymptomatic patients and should be strongly considered. Patients with contraindications to P2Y12 inhibitors may not be appropriate candidates for any CAS procedure. Additionally, alternative types of P2Y12 inhibitors seem to be equally effective as clopidogrel. Finally, an analysis of the Vascular Quality Initiative demonstrates that, even for TCAR cases, only 87.3% of patients seem to be on P2Y12 inhibitors in the periprocedural period, leaving room for significant improvement.

Transcervical radiofrequency ablation of focal adenomyosis: pilot results.

Objective: Adenomyosis is a common gynecological disease, which occurs in women in reproductive age and is characterized by the presence of endometrial glands and stroma within the myometrium. Abnormal uterine bleeding, pelvic pain as well as infertility can be associated with adenomyosis. There are two main types of adenomyosis: diffuse and focal. Previously, adenomyosis was diagnosed only upon histopathological examination after hysterectomy and/or adenomyomectomy. However, the development of imagining techniques such as transvaginal ultrasound and magnetic resonance imaging enables the diagnosis of adenomyosis (diffuse and focal) without any surgical intervention. When medical therapy is contraindicated or ineffective, or if patients have a fertility desire, a surgical treatment may be necessary.Methods: In this study, a total of 13 patients with 16 areas of focal adenomyosis were treated. All patients provided their informed consent to undergo transcervical adenomyosis ablation treatment with the Sonata System, aware that the safety and effectiveness of transcervical radiofrequency (RF) ablation for the treatment of adenomyosis has not been established. Follow-up was performed six months after Sonata treatment.Results: The positive results relating to the improvement of symptoms and reduction of adenomyosis lesion size were observed in our study.Conclusion: Transcervical RF ablation with the Sonata System may be a promising therapeutic alternative method to conventional procedures such as hysterectomy for the treatment of focal adenomyosis, disease which has limited therapeutic approach, and may enable a minimally invasive, uterine preserving option.

Impact of combined endometrial resection or ablation and levonorgestrel intrauterine device on postoperative bleeding pattern.

PURPOSE: The aim of this study was to describe the rate of amenorrhea in women treated with transcervical endometrial resection (TCER) or radiofrequency endometrial ablation combined with levonorgestrel intrauterine contraceptive device (LNG-IUD) six months post-operatively. METHODS: The study was performed as a prospective cohort study. All patients were included at four gynecological centers in Region of Southern Denmark. In total, 162 women referred due to menorrhagia, metrorrhagia or menometrorrhagia and offered TCER or radiofrequency endometrial ablation in combination with or without LNG-IUD included during November 2018 to June 2021 at the women's own discretion and without any cost (covered by the hospital). Data were analyzed using a multivariate regression model. RESULTS: In total, 58 women were offered TCER and 31 (53.4%) combined treatment with TCER + LNG-IUD. Among 104 women who received radiofrequency endometrial ablation, 46 (44.2%) underwent combined treatment with LNG-IUD. The incidence of amenorrhea was 26% among women who underwent treatment with TCRE and 52% when treated with TCER + LNG-IUD (adjusted OR 5.16; 95% CI 1.35-19.6; P < 0.016). Radiofrequency endometrial ablation was followed by a 41% incidence of amenorrhea, and when radiofrequency endometrial ablation was combined with LNG-IUD, the incidence of amenorrhea was 63% (adjusted OR 2.15; 95% CI 0.86-5.37; P < 0.1). We observed no statistically significant differences when comparing the groups across. CONCLUSION: Our study suggests that the combination of TCER or radiofrequency endometrial ablation with LNG-IUD was superior to TCER. However, the combined treatment of radiofrequency endometrial ablation with LNG-IUD did not reach statistical significance. Further studies are needed to evaluate the effects of different ablation techniques on the amenorrhea rate.

Comparison of the efficacy of autologous platelet gel and medical chitosan in the prevention of recurrence of intrauterine adhesions after transcervical resection of adhesion: a prospective, randomized, controlled trial.

PURPOSE: Intrauterine adhesion (IUAs) in women is a debatable topic and there is no clear consensus in its management and treatment strategies. Previous treatment measures have limitations which necessitates to consider effective measures for prevention of recurrence of IUAs. Hence, the aim of this study to explore the efficacy and safety of intrauterine infusion of autologous platelet gel (APG) and medical chitosan in preventing recurrence of IUAs in females after transcervical resection of adhesion (TCRA). METHODS: A prospective, randomized controlled trial was conducted among 80 patients presented with moderate to severe IUAs. Patients were randomized into two groups, APG group (n = 40) and medical chitosan group (n = 40). All patients were injected with either APG or medical chitosan after TCRA. RESULTS: The postoperative recurrence rate of adhesions in APG group was significantly lower than those in medical chitosan group (21% vs 49%). The median AFS score during the second-look hysteroscopy was significantly lower in APG group than in medical chitosan group (P = 0.008). The median AFS score reduction after TCRA surgery was significantly higher in APG group than in medical chitosan group (median, 95% CI 7.000, 6.0 to 8.3 vs. 6.000, 5.0 to 7.0, P = 0.004). Subgroup analysis of platelet concentration (1000 as cut-off value) into high- and low-dose subgroups reported no significant correlation existed between APG and baseline characteristics, recurrence rate and postoperative AFS reduction score except for previous intrauterine operation (P < 0.05). CONCLUSION: Thus, after TCRA, intrauterine injections of APG provides better efficacy and safety compared with intrauterine injections of medical chitosan in preventing recurrence of intrauterine adhesions.

Parapharyngeal space tumors: a twenty-year single-center retrospective analysis on the effectiveness of transcervical and transoral approaches on local control and disease-specific survival.

INTRODUCTION: To retrospectively analyzed our twenty-years single-center experience in the treatment of PPS tumors, focusing on the selection of surgical approach and the survival outcome. METHODS: Tumors involving the PPS between January 2000 and February 2022 were retrospectively included. The surgical approach was dictated by the localization of the tumor, its dimensions, the relation to anatomic structures and its etiology. RESULTS: 34 patients were included in the study. The median age was 50.5 yr, with a gender female prevalence. Most tumors were benign and non recurrent. 20 tumors were treated through lateral approach (transcervical or transcervical-transparotid), 11 through medial approach (transoral), and only 3 tumors were approached by multiple corridors. The 5 years disease free survival (DFS) was 78.8 % (CI 78-79.3 %). CONCLUSIONS: In our experience, the transcervical and transoral approaches can be considered the ideal surgical approach to manage tumors of PPS, especially in cases of benign neoplasms.

Oxidative response of sheep to transcervical applications.

This study aimed to investigate the stress-related changes that may occur in sheep following non-surgical cervical line passage. A total of 20 sheep underwent transcervical transition, and their heart rate, respiratory rate, body temperature, and blood samples were collected at specific time points: 1 h prior to the procedure, immediately after the procedure, and at 1, 2, 3, 4 and 5 h post-procedure. The study found that there was a statistically significant decrease in body temperature immediately after the procedure (p < .05); however, there were no significant differences in body temperature at other time points (p > .05). Respiratory rate remained similar throughout the study, and no significant differences were observed (p > .05). On the other hand, there was a significant increase in heart rate at the 1-h mark after the procedure (p < .05), which subsequently decreased to a similar level as the control group at the 4-h mark after the procedure (p > .05). The cortisol levels increased significantly after the application (p < .05) but decreased to a level similar to the control after 1 h (p > .05). The level of nitric oxide increased significantly in the first hour (p < .05) and decreased by the 5th hour (p < .05). There was a significant increase in malondialdehyde (MDA) and total oxidant capacity (TOC) levels 2 h after the application (p < .05), but this increase ceased at the 4th and 5th hours for MDA (p > .05) and at the 3rd, 4th and 5th hours for TOC (p > .05). The total antioxidant capacity decreased after the 2nd hour of application (p < .05) but remained similar at the fourth and 5th hours (p > .05). In conclusion, based on the cortisol data, transcervical manipulations create short-term stress. Therefore, it may be necessary to use various antioxidants before such procedures to reduce the effects of oxidative stress.

Use of meloxicam with or without dipyrone in non-surgical embryo recovery in hair sheep: Effects on animal welfare.

The aim of this study was to determine the effectiveness of meloxicam with or without dipyrone on the welfare of ewes subjected to non-surgical embryo recovery (NSER). Two studies were carried out using 51 multiparous Santa Inês ewes. All animals received a standard oestrous synchronization treatment and a superovulatory protocol. In Study 1, 12 ewes received meloxicam (GM) before cervical transposition (1 mg kg-1 , i.v.), repeated 24 h after (1 mg kg-1 , i.m.), while the other 10 received a saline solution, remaining as a control group (GC1). In Study 2, ewes were allocated into a group of 15 ewes treated as GM of Study 1 associated with dipyrone (GMD; 50 mg kg-1 , i.m.) before cervical transposition, 12 h, and 24 h after, or a control group (GC2) of 14 ewes treated with saline solution. In both studies, heart and respiratory rates (RR), cortisol, glucose, total proteins, albumin and globulins blood concentration were recorded before sedation (BS), after sedation (AS), after cervical transposition, immediately after collection (IAC), and 0.5, 1.5, 3, 6, 12, 24 and 48 h after embryo collection (hAC). In Study 1, RR tended to be greater in GC1 (p = .08), serum total proteins and globulins values were lower and serum albumin values were greater in this group than GM (p = .003, p < .0001, and p < .0001, respectively). In Study 2, treatment of GMD tended to reduce the glycaemia at AS (p = .052) and reduced it at 3hAC (p < .0001), and 6hAC (p = .03). It also tended to reduce cortisol concentrations (p = .10). The other variables varied with NSER without interaction with the experimental treatments. In conclusion, in this study condition, NSER in sheep induced transient changes indicative of stress and possibly pain, therefore, affecting animal welfare. The administration of meloxicam was ineffective to reduce those responses, and the association of dipyrone had only slight effects without modifying the main welfare indicative responses in ewes subjected to NSER.

Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment and long-term consequences-a retrospective follow-up study.

PURPOSE: The primary aim of this retrospective study was to analyze the progression of descending necrotizing mediastinitis (DNM), evaluate the impact of comorbidities on complications and mortality and to observe long-term consequences of DNM on dysphagia and measurements quality of life. DNM is a serious infectious disease that requires multimodal treatment. Current literature varies in conclusions of risk factors, management and outcome of DNM. In addition, little is known about persisting effects on quality of life. METHODS: Retrospective data analysis of 88 patients with DNM representing the largest single-center study. Recording data of patients and diseases as well as clinical progression from 1997 to 2018. Two questionnaires were sent to the participants to measure quality of life and to detect dysphagia. RESULTS: 88 patients were included. The most frequently found pathogen were Streptococcus spp. (52%). 75% of the patients underwent multiple surgeries, mean count of surgical procedures was 4.3 times. 84% received intensive care treatment. Median length of stay on the intensive care unit was 7 days. 51% had pre-existing comorbidities associated with reduced tissue oxygenation (e.g., diabetes). The most common complication was pleural effusion (45%). During the observation period, the mortality rate was 9%. 12 questionnaires could be evaluated. 67% of the participants were affected by dysphagia at the time of the survey. CONCLUSIONS: Descending necrotizing mediastinitis (DNM) is a severe disease requiring an immediate initiation of multimodal treatment. Although quality of life usually isn´t impaired permanently, dysphagia may often persist in patients after DNM.

Optimal treatment options for uterine submucosal fibroids: Percutaneous microwave ablation versus transcervical resection of myoma.

OBJECTIVES: To compare the efficacy and safety of percutaneous microwave ablation (PMWA) and transcervical resection of myoma (TCRM) for submucosal fibroids. METHODS: From January 2019 to January 2021, we conducted a randomized controlled study involving patients with symptomatic uterine submucosal fibroids. Questionnaires were also used to measure the uterine fibroid symptom (UFS) scores and quality of life (QoL) scores before and after treatment at 3, 6, and 12 months. Outcomes, adverse events, hemoglobin recovery, and submucosal fibroid volume of both groups were also compared. Operation time, amount of bleeding, hospital stay time, and occurrence of complications were compared in groups with fibroids of different lengths. RESULTS: Follow-up after surgery showed that UFS scores at 3, 6, and 12 months were significantly lower in each group, while QoL scores increased significantly. For fibroids less than 3 cm, surgical time was 34.2 ± 9.9 min, incidence of perioperative complications was 4.2%, and both decreased significantly, compared to the surgical time of the PMWA group (40.0 ± 8.1 min) and incidence of perioperative complications (24%; p < .05 for both). For uterine submucosal fibroids >5 cm, the operation time in the PMWA group was 92.7 ± 16.0 min, intraoperative bleeding volume was 22.7 ± 6.4 mL, and hospital stay was 2.7 ± 1.1 days, which were significantly less than the procedural time (107 ± 11.9 min), intraoperative bleeding loss (45.9 ± 12.8 mL), and length of hospital stay (5.0 ± 1.1 days) in the TCRM group. The differences were statistically significant (p < .05). CONCLUSIONS: PMWA and TCRM were both effective treatments for uterine submucosal fibroids. For fibroids shorter than 3 cm in length, especially pedicled submucosal fibroids, TCRM has absolute advantages; however, for uterine submucosal fibroids >5 cm, PMWA avoids perioperative complications, such as uterine perforation, water poisoning syndrome, and the need for repeat surgery, and is considered the preferred mode of treatment. Therefore, personalized treatment should be used for different patients with uterine submucosal fibroids.