Interim analyses with delayed observations in clinical trials

Laparoscopic vs transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy

BACKGROUND

Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event.

OBJECTIVE

The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial.

STUDY DESIGN

Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy.

RESULTS

After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16-6.63; P = .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43-3.37; P = .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence.

CONCLUSION

Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention.

Enoxaparin Versus Unfractionated Heparin in the Prevention of Venous Thromboembolism After Acute Ischemic Stroke: Rationale, Design, and Methods of an Open-Label, Randomized, Parallel-Group Multicenter Trial

BACKGROUND

Small sample size and methodologic limitations make it difficult to interpret and compare trials of low molecular-weight heparin (for example, enoxaparin) versus unfractionated heparin as prophylactic treatment for venous thromboembolism (VTE), that is, deep vein thrombosis and/or pulmonary embolism, in patients with acute ischemic stroke. This prospective, open-label, randomized, parallel-group, multicenter trial is designed to evaluate the efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of VTE after acute ischemic stroke.

METHODS

Approximately 1760 patients with the diagnosis of acute ischemic stroke accompanied by leg paralysis will be randomly assigned (1:1) within 48 hours of stroke symptoms to receive enoxaparin (40 mg subcutaneously) once daily or unfractionated heparin (5000 U subcutaneously) every 12 hours for 10 +/- 4 days. Contrast venography will be used to evaluate asymptomatic patients after treatment for deep vein thrombosis. In addition, diagnostic algorithms will be used to objectively confirm or rule out VTE events for patients in whom upper- or lower-extremity deep vein thrombosis/pulmonary embolism is suggested.

RESULTS

The primary efficacy end point measure will be the cumulative occurrence of documented VTE during the initial treatment period. Secondary end points are VTE incidence; neurologic outcome at days 30, 60, and 90; safety; and health care resource use during initial hospitalization and during the 30- and 90-day follow-up periods.

CONCLUSIONS

This study will provide clinical and health economic data regarding the use of enoxaparin as primary prophylactic treatment of VTE in patients who have had an acute ischemic stroke.