Piglets reared in swine production in the USA undergo painful procedures that include castration, tail docking, teeth clipping, and identification with ear notching or tagging. These procedures are usually performed without pain mitigation. The objective of this project was to develop recommendations for pain mitigation in 1-to 28-day-old piglets undergoing these procedures. The National Pork Board funded project to develop recommendations for pain mitigation in piglets. Recommendation development followed a defined multi-step process that included an evidence summary and estimates of the efficacies of interventions. The results of a systematic review of the interventions were reported in a companion paper. This manuscript describes the recommendation development process and the final recommendations. Recommendations were developed for three interventions (CO 2 /O 2 general anesthesia, non-steroidal anti-inflammatory drugs (NSAIDs), and lidocaine) for use during castration. The ability to make strong recommendations was limited by low-quality evidence and strong certainty about variation in stakeholder values and preferences. The panel strongly recommended against the use of a CO 2 /O 2 general anesthesia mixture, weakly recommended for the use of NSAIDs and weakly recommended against the use of lidocaine for pain mitigation during castration of 1-to 28-day-old piglets.
Surgical adhesions can lead to significant consequences including abdominopelvic pain, bowel obstruction, subfertility, and subsequent surgery. Although laparoscopic surgery is associated with a decreased risk of adhesion formation, methods to further decrease adhesions are warranted. We systematically reviewed literature addressing the management, prevention, and sequelae of adhesions in women undergoing laparoscopic gynecologic surgery. We searched PubMed, EMBASE, EBSCOhost, and Cochrane Central Register of Controlled Trials and found 6566 records. The primary outcome was adhesion formation. The secondary outcomes were abdominopelvic pain, quality of life, subfertility, pregnancy, bowel obstruction, urinary symptoms, and subsequent surgery. After applying inclusion and exclusion criteria, 52 studies remained for qualitative synthesis. Risk of bias assessments were applied independently by 2 authors. There was evidence that Hyalobarrier Gel (Anika Therapeutics, Bedford, MA), HyaRegen NCH Gel (Bilar Medikal, Istanbul, Turkey), Oxiplex/AP Gel (Fziomed, Inc., San Luis Obispo, CA), SprayGel (Confluent Surgical Inc., Waltham, MA), and Beriplast (CSL Behring, LLCm King of Prussia, PA) all decrease the incidence of adhesions. Adept (Baxter, Deerfield, IL) significantly decreased de novo adhesion scores of the posterior uterus. Using an integrated treatment approach to pelvic pain significantly improved pain and quality of life compared with standard laparoscopic treatment. Lastly, Hyalobarrier Gel Endo (Anika Therapeutics, Bedford, MA) placement led to a higher pregnancy rate than no barrier usage. Our findings underscore the need for high-quality trials to evaluate the efficacy of surgical techniques, adhesion barriers, and other treatment modalities on the management and prevention of adhesions and their clinical sequelae. This review was registered on PROSPERO (ID = CRD42017068053).
Objectives The aim of our study was to measure and analyze uterine perfusion utilizing laser angiography with ICG during uterine artery sparing and non-sparing radical trachelectomy. Methods Data were collected from all patients diagnosed with early-stage cervical cancer that underwent laser angiography with ICG during open or laparoscopic radical trachelectomy from June 2012 to December 2015. Regression analysis was use to determine the p values and R-squares on fluorescence, surgical time, hospital stay, age and BMI; a p-value < 0.05 was considered statistically significant. Results A total of 20 patients met the inclusion criteria and were included in this study. Ten patients underwent uterine artery-sparing surgery, and ten patients underwent uterine artery non-sparing surgery. The most frequent stage for the entire cohort was IA2 (55%), and the most common histologic subtype was squamous cell carcinoma (49%). Lymph-vascular invasion was noted in 30% of the patients. There was no statistical significance difference in the mean ICG fundal fluorescence intensity between the uterine artery-sparing group 162.5 (range, 137-188) and the uterine artery non-sparing group 160.5 (range, 135-186), p=0.22. In both groups, 100% of the patients regained their menstrual function by postoperative week 8. A total of 4 (40%) pregnancies have occurred in the uterine artery-sparing group and 3 (30%) in the non-uterine artery-sparing group. Conclusions Based on our real-time intraoperative angiography observations, there is no need to preserve the uterine artery during radical trachelectomy to maintain uterine viability.
Background and Objectives:Vaginal cuff dehiscence may be a vascular-mediated event, and reports show a higher incidence after robot-assisted total laparoscopic hysterectomy (RATLH), when compared with other surgical routes. This study was conducted to determine the feasibility of using laser angiography to assess vaginal cuff perfusion during RATLH.Methods:This was a pilot feasibility trial incorporating 20 women who underwent RATLH for benign disease. Colpotomy was made with ultrasonic or monopolar instruments, whereas barbed or nonbarbed suture was used for cuff closure. Time of instrument activation during colpotomy was recorded. Images were captured of vaginal cuff perfusion before and after cuff closure. Reviewers evaluated these images and determined areas of adequate cuff perfusion.Results:Indocyanine green (ICG) was visible at the vaginal cuff in all participants. Optimal dosage was determined to be 7.5 mg of ICG per intravenous dose. Mean time to appearance for ICG was 18.4 ± 7.3 s (mean ± SD) before closure and 19.0 ± 8.7 s after closure. No significant difference (P = .19) was noted in judged perfusion in open cuffs after colpotomy with a monopolar (48.9 ± 26.0%; mean ± SD) or ultrasonic (40.2 ± 14.1%) device. No difference was seen after cuff closure (P = .36) when a monopolar (70.9 ± 21.1%) or ultrasonic (70.5 ± 20.5%) device was used. The use of barbed (74.1 ± 20.1%) or nonbarbed (66.4 ± 20.9%) sutures did not significantly affect estimated closed cuff perfusion (P = .19). Decreased cuff perfusion was observed with longer instrument activation times in open cuffs (R2 = 0.3175).Conclusion:Laser angiography during RATLH allows visualization of vascular perfusion of the vaginal cuff. The technology remains limited by the lack of quantifiable fluorescence and knowledge of clinically significant levels of fluorescence.
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