Monsel's solution: a kinder, gentler hemostatic

Palliative interventions for controlling vaginal bleeding in advanced cervical cancer

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 5, 2015.Cervical cancer is the fourth most common cancer among women worldwide, with estimated 569,847 new diagnoses and 311,365 deaths per year. However, incidence and stage at diagnosis vary greatly between geographic areas and are largely dependent on the availability of a robust population screening programme. For example, in Nigeria, advanced-stage disease at presentation is common (86% to 89.3% of new cases), whereas in the UK, only 21.9% of women present with International Federation of Gynaecology and Obstetrics (FIGO) stage II+ disease. Women with advanced cancer of the cervix often need palliation for distressing symptoms, such as vaginal bleeding. Vaginal bleeding can be life threatening in advanced disease, with an incidence ranging from 0.7% to 100%. Bleeding is the immediate cause of death in 6% of women with cervical cancer and its management often poses a challenge.Thus, vaginal bleeding remains a common consequence of advanced cervical cancer. Currently, there is no systematic review that addresses palliative interventions for controlling vaginal bleeding caused by advanced cervical cancer. A systematic evaluation of the available palliative interventions is needed to inform decision-making.

OBJECTIVES

To evaluate the efficacy and safety of tranexamic acid, vaginal packing (with or without formalin-soaked packs), interventional radiology or other interventions compared with radiotherapy for palliative treatment of vaginal bleeding in women with advanced cervical cancer.

SEARCH METHODS

The search for the original review was run in 23 March 2015, and subsequent searches for this update were run 21 March 2018. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 3) in the Cochrane Library; MEDLINE via Ovid to March week 2, 2018; and Embase via Ovid to March week 12, 2018. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles, and contacted experts in the field. We handsearched citation lists of relevant studies.

SELECTION CRITERIA

We searched for randomised and non-randomised comparative studies that evaluated the efficacy and safety of tranexamic acid, vaginal packing (with or without formalin-soaked packs), interventional radiology or other interventions compared with radiotherapy techniques for palliative treatment of vaginal bleeding in women with advanced cervical cancer (with or without metastasis), irrespective of publication status, year of publication or language in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no studies for inclusion and, therefore, we analysed no data.

MAIN RESULTS

The search strategy identified 1522 unique references of which we excluded 1330 on the basis of title and abstract. We retrieved the remaining 22 articles in full, but none satisfied the inclusion criteria. We identified only observational data from single-arm studies of women treated with formalin-soaked packs, interventional radiology or radiotherapy techniques for palliative control of vaginal bleeding in women with cervical cancer.

AUTHORS' CONCLUSIONS

Since the last version of this review we found no new studies. There is no evidence from controlled trials to support or refute the use of any of the proposed interventions compared with radiotherapy. Therefore, the choice of intervention will be based on local resources. Radiotherapy techniques for managing vaginal bleeding are not readily available in resource-poor settings, where advanced cases of cervical cancer are predominant. Thus, this systematic review identified the need for a randomised controlled trial assessing the benefits and risks of palliative treatments for vaginal bleeding in women with advanced cervical cancer.

Use of Monsel solution to treat obstetrical hemorrhage: a review and comparison to other topical hemostatic agents

Peripartum hemorrhage accounts for 8% of maternal deaths in the United States, and nearly 27% worldwide. A growing need exists for tactics to spare morbidity given a rise of abnormal placentation that contributes to excessive blood loss at the time of delivery. Approaches such as compression sutures, balloon tamponade, and pelvic artery embolization are not without side effects and potential implications for future fertility. The use of topical hemostatic agents has become widespread in gynecologic and obstetric surgery despite a paucity of distinct studies in the field, and may allow providers to increasingly avoid cesarean hysterectomy. A variety of topical hemostatic agents exist along a wide cost continuum, each characterized by specific efficacy, advantages, drawbacks, and often gaps in long-term data to support safety and impact on future fertility. Herein, we comprehensively review these agents and illustrate a nontraditional use of Monsel solution applied directly to the placental bed in a case of focal placenta accreta. This ultimately contributed to successful uterine preservation with no known adverse sequelae. Monsel solution may have a role in establishing hemostasis in the setting of abnormal placentation, and may be a particularly attractive alternative in resource-poor nations.

Palliative interventions for controlling vaginal bleeding in advanced cervical cancer

BACKGROUND

Cervical cancer is the second most common cancer among women worldwide, with around 500,000 new diagnoses and 273,000 deaths per year. However, incidence and stage at diagnosis vary greatly between geographic areas and are largely dependent on the availability of a robust population screening programme. For example, in Nigeria, advanced-stage disease at presentation is common (86% to 89.3% of new cases), whereas in the UK, only 21.9% of women present with International Federation of Gynaecology and Obstetrics (FIGO) stage II+ disease. Women with advanced cancer of the cervix often need palliation for distressing symptoms, such as vaginal bleeding. Vaginal bleeding can be life threatening in advanced disease, with an incidence ranging from 0.7% to 100%. Bleeding is the immediate cause of death in 6% of women with cervical cancer and its management often poses a challenge.Thus, vaginal bleeding remains a common consequence of advanced cervical cancer. Currently, there is no systematic review that addresses palliative interventions for controlling vaginal bleeding caused by advanced cervical cancer. A systematic evaluation of the available palliative interventions is needed, to inform decision-making.

OBJECTIVES

To evaluate the efficacy and safety of tranexamic acid, vaginal packing (with or without formalin-soaked packs), interventional radiology or other interventions compared with radiotherapy for palliative treatment of vaginal bleeding in women with advanced cervical cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 2, 2015; the Cochrane Gynaecological Cancer Group Trials Register; MEDLINE from 1980 to March week 3, 2015 and EMBASE from 1980 to February week 12, 2015. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles and contacted experts in the field. We handsearched citation lists of relevant studies.

SELECTION CRITERIA

We searched for randomised and non-randomised comparative studies that evaluated the efficacy and safety of tranexamic acid, vaginal packing (with or without formalin-soaked packs), interventional radiology or other interventions compared with radiotherapy techniques for palliative treatment of vaginal bleeding in women with advanced cervical cancer (with or without metastasis), irrespective of publication status, year of publication or language in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no studies were identified for inclusion and, therefore, we analysed no data.

MAIN RESULTS

The search strategy identified 1335 unique references of which 1160 were excluded on the basis of title and abstract. We retrieved the remaining 22 articles in full, but none satisfied the inclusion criteria. We identified only observational data from single-arm studies of women treated with formalin-soaked packs, interventional radiology or radiotherapy techniques for palliative control of vaginal bleeding in women with cervical cancer.

AUTHORS' CONCLUSIONS

There is no evidence from controlled trials to support or refute the use of any of the proposed interventions compared with radiotherapy. Therefore, the choice of intervention will be based on local resources. Radiotherapy techniques for managing vaginal bleeding are not readily available in resource-poor settings, where advanced cases of cervical cancer are predominant. Thus, this systematic review identified the need for a randomised controlled trial assessing the benefits and risks of palliative treatments for vaginal bleeding in women with advanced cervical cancer.

Routine prophylactic application of Monsel's solution after loop electrosurgical excision procedure of the cervix: is it necessary?

AIM

To determine the benefit of an immediate application of Monsel's solution after loop electrosurgical excision procedure (LEEP) of the cervix for preventing postoperative bleeding.

METHODS

This randomized controlled trial was conducted at Chiang Mai University Hospital, Chang Mai, Thailand. Women who were scheduled for LEEP were approached for participation in the study. The primary endpoint was the duration of uncomplicated vaginal bleeding. Secondary endpoints were the incidence of persistent vaginal bleeding, and postoperative complications including severe early bleeding, severe delayed bleeding and infection.

RESULTS

Between October 2004 and May 2006, 285 women with an abnormal Pap-smear, who had undergone LEEP, were randomly allocated to the Monsel's group (n = 140) or control group (n = 145). The baseline outcomes were similar between the two groups. In the Monsel's group, the duration of uncomplicated vaginal bleeding was significantly shorter (P < 0.001) and the occurrence of persistent vaginal bleeding was significantly lower (P = 0.014) than in the control group. The occurrence of severe complications that required treatment, including bleeding and infection, was not significantly different between the two groups (P = 0.379).

CONCLUSION

An application of Monsel's solution after LEEP appears to reduce the duration of postoperative vaginal bleeding, but does not significantly prevent severe complications. Such practice may not be necessary if adequate hemostasis is achieved using electrical cauterization.

New approaches in ambulatory proctology

Ambulatory proctology is till now very underestimated discipline, which is out of interest of big surgeons. But is is a very important field due to incidence of proctological affections and severe social consequences of their inappropriate diagnosis and treatment. We stress the conservative and semi-invasive treatment of hemorrhoids, anal thrombosis and anal fissures. We also mention the other anal pathologies.