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Fluid and Pharmacological Agents for Adhesion Prevention After Gynaecological Surgery (Review)

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Fluid and Pharmacological Agents for Adhesion Prevention After Gynaecological Surgery (Review) Fluid and pharmacological agents for adhesion prevention after gynaecological surgery (Review) Ahmad G, Mackie FL, Iles DA, O’Flynn H, Dias S, Metwally M, Watson A This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2014, Issue 7 http://www.thecochranelibrary.com Fluid and pharmacological agents for adhesion prevention after gynaecological surgery (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 PLAINLANGUAGESUMMARY . 2 SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . ..... 4 BACKGROUND .................................... 6 OBJECTIVES ..................................... 7 METHODS ...................................... 7 RESULTS....................................... 9 Figure1. ..................................... 10 Figure2. ..................................... 12 Figure3. ..................................... 13 Figure4. ..................................... 14 Figure5. ..................................... 15 Figure6. ..................................... 16 Figure7. ..................................... 17 Figure8. ..................................... 18 Figure9. ..................................... 18 Figure10. ..................................... 19 ADDITIONALSUMMARYOFFINDINGS . 22 DISCUSSION ..................................... 32 AUTHORS’CONCLUSIONS . 33 ACKNOWLEDGEMENTS . 33 REFERENCES ..................................... 33 CHARACTERISTICSOFSTUDIES . 36 DATAANDANALYSES. 83 Analysis 1.1. Comparison 1 Hydroflotation agent vs no hydroflotation agent, Outcome 1 Improvement in pelvic pain at second-looklaparoscopy. 86 Analysis 1.2. Comparison 1 Hydroflotation agent vs no hydroflotation agent, Outcome 2 Live birth rate. 86 Analysis 1.3. Comparison 1 Hydroflotation agent vs no hydroflotation agent, Outcome 3 Improvement in adhesion score atSLL..................................... 87 Analysis 1.4. Comparison 1 Hydroflotation agent vs no hydroflotation agent, Outcome 4 Number of participants with worseningadhesionscore. 88 Analysis 1.5. Comparison 1 Hydroflotation agent vs no hydroflotation agent, Outcome 5 Number of participants with adhesions at second-look laparoscopy. ..... 88 Analysis 1.6. Comparison 1 Hydroflotation agent vs no hydroflotation agent, Outcome 6 Mean adhesion score at second- looklaparoscopy.. 89 Analysis 1.7. Comparison 1 Hydroflotation agent vs no hydroflotation agent, Outcome 7 Clinical pregnancy rate. 90 Analysis 1.9. Comparison 1 Hydroflotation agent vs no hydroflotation agent, Outcome 9 Ectopic pregnancy rate (per pregnancy). .................................. 91 Analysis 2.3. Comparison 2 Gel agent vs no treatment, Outcome 3 Number of participants with improvement in adhesion score...................................... 92 Analysis 2.4. Comparison 2 Gel agent vs no treatment, Outcome 4 Number of participants with worsening adhesion score...................................... 92 Analysis 2.5. Comparison 2 Gel agent vs no treatment, Outcome 5 Number of participants with adhesions at second-look laparoscopy. .................................. 93 Analysis 2.6. Comparison 2 Gel agent vs no treatment, Outcome 6 Mean adhesion score at second-look laparoscopy. 93 Analysis 3.3. Comparison 3 Gel agent vs hydroflotation agent when used as an instillant, Outcome 3 Number of participants with improvement in adhesion score. ..... 94 Analysis 3.4. Comparison 3 Gel agent vs hydroflotation agent when used as an instillant, Outcome 4 Number of participants with worsening adhesion score. 95 Fluid and pharmacological agents for adhesion prevention after gynaecological surgery (Review) i Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Analysis 3.5. Comparison 3 Gel agent vs hydroflotation agent when used as an instillant, Outcome 5 Number of participants with adhesions at second-look laparoscopy. ........ 95 Analysis 3.6. Comparison 3 Gel agent vs hydroflotation agent when used as an instillant, Outcome 6 Mean adhesion score atsecond-looklaparoscopy. 96 Analysis 4.2. Comparison 4 Steroid (any route) vs no steroid, Outcome 2 Live birth rate. 96 Analysis 4.3. Comparison 4 Steroid (any route) vs no steroid, Outcome 3 Number of participants with improvement in adhesionscore. ................................. 97 Analysis 4.4. Comparison 4 Steroid (any route) vs no steroid, Outcome 4 Number of participants with worsening adhesion score...................................... 97 Analysis 4.7. Comparison 4 Steroid (any route) vs no steroid, Outcome 7 Clinical pregnancy rate. 98 Analysis 4.9. Comparison 4 Steroid (any route) vs no steroid, Outcome 9 Ectopic pregnancy rate (per pregnancy). 98 Analysis 5.4. Comparison 5 Intraperitoneal noxytioline vs no treatment, Outcome 4 Number of participants with worsening adhesionscore. ................................. 99 Analysis 5.7. Comparison 5 Intraperitoneal noxytioline vs no treatment, Outcome 7 Clinical pregnancy rate. 100 Analysis 5.9. Comparison 5 Intraperitoneal noxytioline vs no treatment, Outcome 9 Ectopic pregnancy rate (per pregnancy). .................................. 100 Analysis 6.3. Comparison 6 Intraperitoneal heparin solution vs no intraperitoneal heparin, Outcome 3 Number of participants with improvement in adhesion score. ........... 101 Analysis 6.4. Comparison 6 Intraperitoneal heparin solution vs no intraperitoneal heparin, Outcome 4 Number of participants with worsening adhesion score. ......... 101 Analysis 7.3. Comparison 7 Systemic promethazine vs no promethazine, Outcome 3 Number of participants with improvementinadhesionscore. 102 Analysis 7.4. Comparison 7 Systemic promethazine vs no promethazine, Outcome 4 Number of participants with worseningadhesionscore. 102 APPENDICES ..................................... 103 WHAT’SNEW..................................... 109 HISTORY....................................... 110 CONTRIBUTIONSOFAUTHORS . 110 DECLARATIONSOFINTEREST . 110 SOURCESOFSUPPORT . 111 DIFFERENCES BETWEEN PROTOCOL AND REVIEW . .... 111 INDEXTERMS .................................... 111 Fluid and pharmacological agents for adhesion prevention after gynaecological surgery (Review) ii Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. [Intervention Review] Fluid and pharmacological agents for adhesion prevention after gynaecological surgery Gaity Ahmad1, Fiona L Mackie1, David A Iles2, Helena O’Flynn3, Sofia Dias4, Mostafa Metwally5, Andrew Watson6 1Obstetrics & Gynaecology, Pennine Acute NHS Trust, Manchester, UK. 2Obstetrics and Gynaecology, Blackpool Victoria Hospital, Blackpool, UK. 3University Hospital of South Manchester, Manchester, UK. 4School of Social and Community Medicine, University of Bristol, Bristol, UK. 5The Jessop Wing and Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK. 6Tameside & Glossop Acute Services NHS Trust, Tameside General Hospital, Ashton-Under-Lyne, UK Contact address: Gaity Ahmad, Obstetrics & Gynaecology, Pennine Acute NHS Trust, Manchester, UK. [email protected]. [email protected]. Editorial group: Cochrane Menstrual Disorders and Subfertility Group. Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 7, 2014. Review content assessed as up-to-date: 7 April 2014. Citation: Ahmad G, Mackie FL, Iles DA, O’Flynn H, Dias S, Metwally M, Watson A. Fluid and pharmacological agents for adhesion prevention after gynaecological surgery. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD001298. DOI: 10.1002/14651858.CD001298.pub4. Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background Adhesions are fibrin bands that are a common consequence of gynaecological surgery. They are caused by various conditions including pelvic inflammatory disease and endometriosis. Adhesions are associated with considerable co-morbidity, including pelvic pain, sub- fertility and small bowel obstruction. Patients may require further surgery-a fact that has financial implications. Objectives To evaluate the role of fluid and pharmacological agents used as adjuvants in preventing formation of adhesions after gynaecological surgery. Search methods The following databases were searched up to April 2014: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. Studies involving hydroflotation, gel and such pharmacological agents as steroids, noxytioline, heparin, promethazine, N,O-carboxymethyl chitosan and gonadotrophin- releasing hormone agonists were evaluated. Selection criteria Randomised controlled trials investigating the use of fluid and pharmacological agents to prevent adhesions after gynaecological surgery. Gels were defined as fluid agents. Data collection and analysis Three review authors independently assessed trials for eligibility, extracted data and evaluated risk of bias. Results were expressed as odds ratios (ORs), mean differences (MDs) or standard mean differences (SMDs) as appropriate, with 95% confidence intervals (CIs). Fluid and pharmacological agents for adhesion prevention after gynaecological surgery (Review) 1 Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Main results Twenty-nine trials were included (3227 participants), and nine were excluded. One study examined pelvic
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