RESUMO
Supraventricular tachycardia (SVT) is one of the most common cardiac arrhythmias, characterized by a sudden increase in heart rate. Initial management often involves vagal maneuvers, including the Valsalva maneuver (VM) and carotid sinus massage (CSM). VM can be categorized into standard VM (sVM) and modified VM (mVM). This study aimed to synthesize the first evidence from published randomized controlled trials (RCTs) comparing the efficacy of VM versus CSM. A comprehensive search across databases, including PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar, was conducted up to July 29, 2024. The primary endpoint was the success rate of converting SVT to sinus rhythm. The dichotomous outcome was analyzed using a fixed-effect model to calculate the risk ratio (RR) and 95% confidence intervals (CI). The Risk of Bias (RoB) tool, version 2, was employed to assess bias in the included RCTs. In total, three RCTs with 346 cases were analyzed. Concerns were noted regarding potential bias related to the randomization process in all three studies. The meta-analysis of these RCTs (comprising four arms) revealed that VM had a higher success rate than CSM for treating SVT, with an RR of 1.82 (95% CI: 1.29-2.57, p<0.001). Subgroup analysis showed that the rate of conversion to sinus rhythm was significantly higher in the sVM compared to CSM (RR=1.61, 95% CI (1.13-2.29), p=0.01). Additionally, subgroup analysis of one study indicated that mVM was associated with a higher rate of SVT conversion to sinus rhythm compared to CSM (RR=9.28, 95% CI (1.25-69.13), p=0.03). In conclusion, VM demonstrated a higher success rate compared to CSM in treating SVT. Specifically, mVM was more effective than CSM in both terminating SVT and restoring sinus rhythm, though this evidence was based on a single RCT; hence, the related conclusion should be interpreted with caution and requires validation using additional RCTs. Further research in diverse patient populations and clinical settings is necessary to validate these findings and potentially support the broader use of mVM in practice. Additional well-designed, multi-center studies with diverse populations are needed to confirm these observations and provide more comprehensive guidance on SVT management. This is important to enhance the generalizability of results across different demographics and clinical settings. This approach helps ensure that treatment effectiveness is applicable to a broader range of patients, accounting for variations in age, gender, comorbidities, and regional practices.
RESUMO
BACKGROUND: Obesity is a risk factor for gallstone formation, which can be exacerbated by bariatric surgery-induced rapid weight loss. Current guidelines do not recommend concomitant cholecystectomy (CC) for asymptomatic gallstones during the bariatric surgery procedure. However, long-term follow-up studies have shown that the incidence of post-bariatric surgery symptomatic gallstones necessitating therapeutic cholecystectomy increases to 40%. Therefore, some surgeons advocate simultaneous cholecystectomy during the bariatric surgery for asymptomatic individuals. This study aims to evaluate the safety of performing cholecystectomy for asymptomatic gallstones during the bariatric procedure. METHODS: Data from a consecutive series of patients that underwent primary laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB) or conversion of LSG to a LRYGB with or without concomitant cholecystectomy for asymptomatic gallstones between Jan 2010 and Dec 2017 were retrieved from the database. The primary endpoint was the complication rate. Secondary endpoints were the surgical operating room time (ORT) and the length of hospital stay (LOS). RESULTS: Out of the 2828 patients who were included, 120 patients underwent a concomitant cholecystectomy during their bariatric procedure (LSG or LRYGB) for asymptomatic gallbladder stones and were compared to the 2708 remaining patients who only had bariatric surgery. None of the concomitant cholecystectomy patients developed a gallbladder-related complication. There was no significant increase in the rate of minor or major complications between the CC groups and the non-CC groups (LSG: 6.7% vs. 3.2%, p=0.132; LRYGB: 0% vs. 2.3%, p =0.55; and conversion of LSG to LRYGB: 20% vs. 7.1%, p = 0.125, respectively). In addition, there was no significant increase in the length of hospital stay (1.85 ±4.19 days vs. 2.24 ±1.82, p=0.404) for LSG group and (1.75 ±2.0 vs. 2.3 ±2.1, p=0.179) for LRYGB group. Adding the cholecystectomy to the bariatric procedure only added an average of 23 min (min) (27 min when added to LSG and 18 min when added to LRYGB). CONCLUSION: As one of the largest series reviewing concomitant cholecystectomy in bariatric surgery, this study showed that in skilled laparoscopic bariatric surgical hands, concomitant cholecystectomy during bariatric surgery is safe and prevents potential future gallstone-related complications. Long-term large prospective randomized trials are needed to further clarify the recommendation of prophylactic concomitant cholecystectomy during bariatric surgery.