Situaciones transoperatorias en pacientes pediátricos con fractura supracondílea del húmero

Introducción: Las fracturas supracondíleas del húmero en el niño, por lo general, son tratadas de manera quirúrgica, durante esa intervención se pueden presentar situaciones específicas en este tipo de enfermos. Objetivo: Actualizar y brindar información sobre algunas de las situaciones transoperatorias en pacientes con fractura supracondílea del húmero. Métodos: La búsqueda y análisis de la información se realizó en un periodo de 61 días (primero de septiembre al 31 de octubre de 2022) y se emplearon palabras de búsqueda relacionadas con la investigación. A partir de la información obtenida, se realizó una revisión bibliográfica de un total de 245 artículos publicados en las bases de datos: PubMed, Hinari, SciELO y Medline, mediante el gestor de búsqueda y administrador de referencias EndNote, de ellos, se utilizaron 29 citas seleccionadas para realizar la revisión, 28 de los últimos cinco años. Resultados: Se hace referencia a cuatro de las situaciones transoperatorias más frecuentes en este tipo de fractura. Se mencionan la conminución de la pared medial, como identificar esta situación y su conducta. En relación a las lesiones asociadas, se recomienda primero estabilizar el antebrazo y luego la fractura supracondílea. Para las fracturas inestables en flexión se recomienda la técnica a emplear. Por su parte, la conversión de la reducción cerrada a abierta está justificada en ciertas circunstancias que de forma detallada se describen en el trabajo. Conclusiones: Las fracturas supracondíleas del húmero en el niño son tratadas en su mayoría mediante tratamiento quirúrgico. Durante el transoperatorio se pueden presentar situaciones para las cuales el médico tratante debe estar preparado.

Introduction: Supracondylar fractures of the humerus in children are generally treated surgically, during surgery intervention may occur specific situations in this type of patient. Objective: To update and provide information on some of the intraoperative situations in patients with supracondylar fracture of the humerus. Methods: The search and analysis of the information was carried out in a period of 61 days (September 1st to October 31st, 2022) and search words related to the investigation were used. Based on the information obtained, a bibliographic review of a total of 245 articles published in the PubMed, Hinari, SciELO and Medline databases was carried out using the EndNote search manager and reference administrator, of which 29 selected citations were used to carry out the review, 28 of the last five years. Results: Reference is made to four of the most frequent intraoperative situations in this type of fracture. Comminution of the medial wall, how to identify this situation and its behavior are mentioned. In relation to associated injuries, it is recommended to first stabilize the forearm and then the supracondylar fracture. For unstable fractures in flexion, the technique to be used is recommended. For its part, the conversion from closed to open reduction is justified in certain circumstances that are described in the article. Conclusions: Supracondylar fractures of the humerus in children are mostly treated by surgical treatment. During the trans-operative period situations may arise for which the treating physician must be prepared.

Early or Delay? The Most Suitable Rehabilitation Protocol for "No Man's Land" Injury: Meta-Analysis with Trial Sequential Analysis - 20 Years Trends / Precoce ou tardio? O protocolo de reabilitação mais adequado para lesão na região 'terra de ninguém': Metanálise com análise sequencial de ensaios - Tendências de 20 anos

Abstract Objective The aim of this study is to analyze various rehabilitation protocol and determine which methods will yield a better outcome. Methods The database reports were searched within 1990 until 2020, using PubMed, Cochrane library database, Ovid, Medline, and the other several published trials. A statistical analysis was made from Review Manager and Trial Sequential Analysis (TSA). Result The mean of re-rupture rate is 3.3% (n= 8) in the combination protocol until 8% (n= 48) in CAM protocol. Meta-analyses found no significant difference between Kleinert vs CAM in re-rupture rate. Also no significant difference in Duran vs CAM in rerupture rate. In Trial Sequential Analysis (TSA), the z-curve does not cross both of the trial sequential boundaries, a further trial with larger sample will be required. The TSA of flexion contracture CAM vs Kleinert was indicated that CAM protocol may be superior than Kleinert to reduce the incidence of flexion contracture. For the range of mean flexion contracture 6.6% (n= 18) in CAM to 23.6% (n= 76) in Kleinert protocol. Conclusion Current meta-analysis proposed that the combination technique will result less re-rupture incidence and better functional outcome in flexor zone II injuries than other techniques. The CAM method also results less flexion contracture than others. However, a further meta-analyses with larger sample trials will be required to confirm this review's conclusion.

Resumo Objetivo O objetivo deste estudo é analisar vários protocolos de reabilitação e determinar quais métodos produzem um melhor resultado. Métodos Os relatórios dos bancos de dados foram pesquisados entre 1990 e 2020, usando PubMed, banco de dados da biblioteca Cochrane, Ovid, Medline e vários outros ensaios publicados. Uma análise estatística foi feita a partir do Review Manager e Trial Sequential Analysis (TSA). Resultado A taxa média de re-ruptura é de 3,3% (n = 8) no protocolo combinado, e até 8% (n = 48) no protocolo de Movimento Ativo Controlado (MAC). As metanálises não encontraram diferença significativa entre Kleinert vs MAC na taxa de re-ruptura. Também não há diferença significativa entre Duran e MAC na taxa de re-ruptura. Na Trial Sequential Analysis (TSA), a curva z não cruza ambos os limites sequenciais de ensaio, será necessário um ensaio adicional com amostra maior. A TSA de contratura em flexão MAC vs Kleinert indicou que o protocolo MAC pode ser superior ao Kleinert para reduzir a incidência de contratura em flexão. Para a faixa de contratura média em flexão de 6,6% (n = 18) no MAC a 23,6% (n = 76) no protocolo Kleinert. Conclusão A metanálise atual propôs que a técnica combinada resultará em menor incidência de re-ruptura e melhor resultado funcional em lesões da zona flexora II do que outras técnicas. O método MAC também resulta em menos contratura em flexão do que outros. No entanto, serão necessárias mais metanálises com estudos com amostras maiores para confirmar a conclusão desta revisão.

Riesgo de accidente cerebrovascular en pacientes con aterosclerosis carotídea asintomática: ¿se debe tratar médicamente o quirúrgicamente?

Los desórdenes cerebrovasculares siguen siendo la primera causa de morbilidad y mortalidad neurológica en el mundo, representando una de las entidades patológicas que genera mayor carga de enfermedad a nivel global. La aterosclerosis, o estenosis carotídea, es un potencial factor de riesgo para el ictus isquémico. La identificación y seguimiento estricto de esta condición son esenciales en la prevención secundaria de complicaciones a través de la atención primaria y el manejo especializado del riesgo cardiometabólico. No obstante, dependiendo de este riesgo y/o la presencia de sintomatología, es necesario realizar un manejo definitivo. Actualmente, existe controversia sobre si es mejor tratar la estenosis carotídea asintomática, ya sea médica o quirúrgicamente. Teniendo en cuenta la relevancia de esta entidad, el objetivo de esta revisión consiste en analizar la evidencia reciente sobre el riesgo de ictus isquémico en la aterosclerosis carotídea asintomática en adultos, y el potencial beneficio del manejo quirúrgico vs. farmacológico de esta condición. Para esto, se llevó a cabo una búsqueda bibliográfica en las bases de datos PubMed, ScienceDirect, Web of Science y MEDLINE, hasta el año 2023. Se evidenció que el riesgo de ictus asociado a estenosis carotídea asintomática es significativo (>10 %, aproximadamente), incluso en aquellos con terapia antiplaquetaria e hipolipemiante activa. En aquellos con manejo médico, la supervivencia a cinco años es alrededor del 80 %. Sin embargo, la progresión de la estenosis sucede en promedio en más del 60 % de los casos, y es significativa. Por el contrario, el stent carotídeo y la endarterectomía son intervenciones resolutivas. Pero existe un riesgo mayor comparado con la terapia médica, el cual se atribuye al periodo periy posoperatorio, así como a 30 días de aparición o recurrencia del ictus, infarto agudo de miocardio o muerte por cualquier causa; aunque el uso de la endarterectomía ha demostrado beneficios superiores a largo plazo en cuanto a estos mismos desenlaces. Entonces, la evidencia es heterogénea en cuanto a la superioridad del tratamiento quirúrgico comparado con la terapia farmacológica en el manejo de la aterosclerosis o estenosis carotídea asintomática. Sin embargo, parece ser que el manejo quirúrgico, específicamente la endarterectomía, podría impactar significativamente sobre la aparición o recurrencia del ictus ipsilateral y muerte a largo plazo, pero con resultados controversiales periy postoperatorios.

Cerebrovascular disorders remain the leading cause of neurological morbidity and mortality in the world, representing one of the pathological entities responsible for the greatest burden of disease worldwide. Carotid atherosclerosis or stenosis is a potential risk factor for ischemic stroke. The identification and strict follow-up of this condition are essential in the secondary prevention of complications through primary care and the specialized treatment of cardiometabolic risk. However, depending on this risk and/or presence of symptoms, definitive treatment is necessary. Currently, there is controversy as to whether asymptomatic carotid stenosis is better to be treated medically or surgically. Considering the significance of such entity, this review aims to analyze recent evidence on the risk of ischemic stroke in the case of asymptomatic carotid atherosclerosis among adults, as well as the potential benefit of the surgical vs. pharmacological treatment for this condition. For this purpose, a literature search for publications up to 2023 was carried out in PubMed, ScienceDirect, Web of Science and MEDLINE databases. It was shown that there is a significant risk of stroke associated with asymptomatic carotid stenosis (> 10 % approximately), even in patients with active antiplatelet and lipid-lowering therapy. Out of all those who receive medical treatment, around 80 % had a five-year survival rate. However, stenosis progression occurs on average in more than 60 % of the cases and is significant. On the other hand, carotid stenting and endarterectomy are curative interventions. Nevertheless, these procedures involve a higher risk compared to the medical therapy during the periand postoperative period, as well as 30 days afterwards, due to the occurrence or recurrence of stroke, acute myocardial infarction or death from any cause. Despite this, the use of endarterectomy has shown superior long-term benefits concerning these same outcomes. Thus, evidence regarding the superiority of surgical treatment compared to pharmacological treatment for asymptomatic carotid atherosclerosis or stenosis is heterogeneous. However, it seems that surgical treatment, specifically endarterectomy, could have a significant impact on the occurrence or recurrence of ipsilateral stroke and death in the long term but with controversial periand postoperative outcomes.

Desenlaces negativos y mortalidad en el anciano frágil sometido a cirugía mayor: ¿qué factores de riesgo impactan más?

El adulto mayor, con frecuencia frágil, es un paciente susceptible a un sinnúmero de complicaciones, tanto inmediatas como a corto, mediano y largo plazo, posterior a una intervención quirúrgica. En función de las comorbilidades presentadas, se debe hacer un abordaje integral para alcanzar el mejor estado orgánico previo a la cirugía e intentar mantenerlo durante y posterior a la intervención. Considerar la fuerza estadística de los desenlaces negativos y, específicamente, de la mortalidad en adultos mayores sometidos a cirugía mayor, es verdaderamente un reto. Incluso, esto trasciende a otros campos como la bioética, al plantearse un dilema sobre la distanasia, cuando se recurre a ciertas intervenciones riesgosas en aquellos con un pronóstico de vida temeroso. Recientemente, se ha publicado evidencia interesante que ha estimado la incidencia, riesgo de mortalidad y factores asociados a desenlaces negativos en adultos mayores sometidos a cirugía mayor, planteando posibles modificaciones en los algoritmos de toma de decisiones en futuras guías de práctica clínica en cirugía. El objetivo de esta revisión consiste en analizar evidencia actualizada sobre qué factores de riesgo impactarían más sobre desenlaces negativos y mortalidad en el adulto mayor sometido a cirugía mayor. Se realizó una búsqueda bibliográfica utilizando los términos de búsqueda "Cirugía Mayor" y "Adulto Mayor", además de sinónimos, en las bases de datos PubMed, ScienceDirect, Web of Science y MEDLINE. En cirugía general y subespecialidades, es muy complejo determinar factores de riesgo precisos y extrapolables a todos los escenarios quirúrgicos, debido a la complejidad y especificidad de ciertos órganos y procedimientos. Existe evidencia sobre adultos frágiles que son sometidos a cirugía por cáncer colorrectal, metástasis hepática, cáncer de pulmón, enfermedad pancreática y cáncer esofágico, en donde se registra una mayor estancia hospitalaria; y de forma general, la mortalidad es mayor en aquellos sometidos a cirugía oncológica. No obstante, tanto la integridad física como mental se asocian con peores desenlaces, y la prehabilitación quirúrgica podría impactar de manera positiva sobre esta situación, al mejorar la reserva funcional y tiempo de recuperación posquirúrgico.

The elderly, often frail, are patients susceptible to numerous complications, both immediate and in the short, medium and long term, following surgical interventions. Depending on their comorbidities, a comprehensive approach should be taken to achieve the best condition of the organs prior to surgery and attempt to maintain it during and after the intervention. Considering the statistical strength of negative outcomes, specifically mortality in elderly patients undergoing major surgery, is truly a challenge. This even extends to other fields such as bioethics, raising a dilemma about dysthanasia when resorting to certain risky interventions in those with a fearful life prognosis. Recently, interesting evidence estimating the incidence, mortality risk and factors associated with negative outcomes in elderly patients undergoing major surgery has been published, suggesting possible modifications in decision-making algorithms for future clinical practice guidelines in surgery. The objective of this review is to analyze updated evidence on which risk factors would have the greatest impact on negative outcomes and mortality in elderly patients undergoing major surgery. A literature search was conducted using the search terms "Major Surgery" and "Elderly," in addition to synonyms, in the PubMed, ScienceDirect, Web of Science and MEDLINE databases. In general surgery and subspecialties, it is very complex to determine precise risk factors that can be extrapolated to all surgical scenarios due to the complexity and specificity of certain organs and procedures. Evidence has found that frail adults undergoing surgery for colorectal cancer, liver metastasis, lung cancer, pancreatic disease and esophageal cancer have the longest hospital stays, and overall mortality is higher in those undergoing oncologic surgery. However, both physical and mental integrity are associated with worse outcomes, and surgical prehabilitation could positively impact this situation by improving functional reserve and post-surgical recovery time.

The influence of 3D renal reconstruction on surgical planning for complex renal tumors: An interactive case-based survey

ABSTRACT Objectives To evaluate the role of three-dimensional (3D) reconstruction in preoperative planning for complex renal tumors. Materials and Methods A well-planned questionnaire was distributed among the attending urologists at an international meeting. The questionnaire inquired about demographic data, surgical experience, partial nephrectomy (PN) versus radical nephrectomy (RN), surgical approach, time of ischemia, probability of postoperative urine leakage and positive surgical margins after viewing computed tomography (CT) scans and their respective 3D models of six complex renal tumors. Following the CT scans, attendees were asked to view randomly selected reconstructions of the cases. Results One hundred expert urologists participated in the study; 61% were aged between 40 and 60 years. Most of them (74%) were consultants. The overall likelihood of PN after viewing the 3D reconstructions significantly increased (7.1±2.7 vs. 8.0±2.2, p<0.001), the probability of conversion to RN significantly decreased (4.3±2.8 vs. 3.2±2.5, p<0.001), and the likelihood of urine leakage and positive surgical margins significantly decreased (p<0.001). Preference for the open approach significantly decreased (21.2% vs. 12.1%, p<0.001), while selective clamping techniques significantly increased (p<0.001). After viewing the 3D models, low expected warm ischemia time and estimated blood loss were significantly preferred by the respondents (p<0.001). Surgical decision change was significantly associated with performance or participation in more than 20 PNs or RNs annually [3.25 (1.98-5.22) and 2.87 (1.43-3.87), respectively]. Conclusions 3D reconstruction models play a significant role in modifying surgeons' strategy and surgical planning for patients with renal tumors, especially for patients with stronger indications for a minimally invasive and/or nephron-sparing approach.

Outcomes of the Carlson Approach in the Treatment of Posterior Tibial Plateau Fractures / Resultados da abordagem de Carlson para o tratamento de fraturas no platô tibial posterior

Abstract Objectives To describe a series of cases of tibial fractures surgically treated using the posterior approach as described by Carlson, focusing on evaluating its functional results and complication rate. Methods Eleven patients with tibial plateau fractures, who underwent surgical treatment using the Carlson approach from July to December 2019, were followed-up. The minimum follow-up period was defined as 6 months. The American Knee Society Score (AKSS), American Knee Society Score/Function (AKSS/Function) and the Lysholm score were used to check treatment results at 6 months after the fracture. The patients underwent standard anteroposterior and lateral radiographs to assess fracture healing, and clinical healing was determined by the absence of pain during full weight-bearing. Results The mean follow-up period was 12 months (9-16 months). The primary mechanism of trauma was motorcycle accident, and the most prevalent side of fracture was the right side. Eight participants were male. The mean age of the patients was 28 years. All fractures healed, and none of the patients presented complications. The AKSS was excellent in 11 patients, with a mean AKSS/Function of 99.1±3, and Lysholm scores with a median of 95.0±5.6. Conclusions The Carlson approach for posterior fractures of the tibial plateau can be considered safe, presenting a low complication rate and satisfactory functional results.

Resumo Objetivos O objetivo deste trabalho é descrever uma série de casos de fraturas de tíbia submetidas ao tratamento cirúrgico pela via posterior de Carlson para avaliação de resultados funcionais e frequência de complicações. Métodos Onze pacientes com fraturas do platô tibial foram submetidos a tratamento cirúrgico pela via de Carlson de julho a dezembro de 2019 e acompanhados por um período mínimo de 6 meses. As pontuações American Knee Society Score (AKSS), American Knee Society Score/Function (AKSS/Função) e de Lysholm verificaram os resultados do tratamento 6 meses após a fratura. Os pacientes foram submetidos a radiografias comuns em incidência anteroposterior e de perfil para avaliação da consolidação da fratura e a cicatrização clínica foi determinada pela ausência de dor à descarga total de peso. Resultados O período médio de acompanhamento foi de 12 meses (9 a 16 meses). O principal mecanismo de trauma foi acidente motociclístico e a fratura foi mais prevalente no lado direito. Oito pacientes eram do sexo masculino. A média de idade dos pacientes foi de 28 anos. Todas as fraturas cicatrizaram e nenhum paciente apresentou complicações. A AKSS foi excelente em 11 pacientes, com AKSS/Função média de 99,1 ±3, e a mediana das pontuações de Lysholm foi de 95,0 ±5,6. Conclusões Nas fraturas posteriores do platô tibial, a abordagem de Carlson pode ser considerada segura, apresentando baixo índice de complicações e resultados funcionais satisfatórios.

Nursing Care Related with Surgical Position / Cuidados de enfermería relacionados con la posición quirúrgica / Cuidados de enfermagem relacionados à posição cirúrgica

The patient's correct position is necessary to conduct a safe and effective surgical procedure. This position depends on the access route, duration of the procedure, kind of anesthesia, devices to use, among other factors. This procedure requires planning and effort by the surgical team where they share responsibility to establish and maintain the correct positions for patients. Each surgical position fulfills an objective and implies risks to patients, which is why nursing professionals must be very attentive to provide the necessary care and ensure reliable practices in each position during the perioperative, the importance of the documentation, and the NANDA, NIC, and NOC taxonomy to consider.

La correcta posición del paciente es necesaria para el desarrollo de un procedimiento quirúrgico seguro y eficaz. Esta posición depende de la vía de acceso, la duración del procedimiento, el tipo de anestesia, los dispositivos a utilizar entre otros factores. Este procedimiento requiere planeación y esfuerzo del equipo quirúrgico donde se comparten responsabilidad para establecer y mantener las posiciones correctas para los pacientes. Cada posición quirúrgica cumple un objetivo e implica un riesgo para el paciente, por lo que los profesionales de enfermería deben estar muy atentos para brindar los cuidados necesarios y asegurar prácticas confiables en cada posición durante el perioperatorio, la importancia de la documentación y la taxonomía NANDA, NIC y NOC a tener en cuenta.

A posição correta do paciente é necessária para o desenvolvimento de um procedimento cirúrgico seguro e eficaz. Essa posição depende da via de acesso, da duração do procedimento, do tipo de anestesia, dos aparelhos a serem utilizados, entre outros fatores. Este procedimento requer planejamento e esforço da equipe cirúrgica onde a responsabilidade é compartilhada para estabelecer e manter as posições corretas dos pacientes. Cada posição cirúrgica cumpre um objetivo e implica um risco para o paciente, por isso os profissionais de enfermagem devem estar muito atentos para prestar os cuidados necessários e garantir práticas confiáveis em cada posição durante o período perioperatório, a importância da documentação e taxonomia NANDA, NIC e NOC para levar em conta.

Treatment of patients with sentinel bleeding after hepatobiliary and pancreatic surgery / 中华肝胆外科杂志

Objective:To compare the results of operative versus interventional treatments in patients presenting with sentinel hemorrhage after hepatobiliary and pancreatic surgery.Methods:The clinical data of patients presenting with sentinel hemorrhage after hepatobiliary and pancreatic surgery at the Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Guangzhou Medical University from August 2017 to July 2022 were retrospectively analyzed. Of 82 patients who were enrolled in this study, there were 50 males and 32 females, aged (59.0±7.7) years. The patients were divided into the interventional group ( n=42) and the surgical group ( n=40) based on the treatment they received for sentinel hemorrhage. The vascular injury rate, the first operation time for sentinel bleeding, the rate of successful hemostasis in a single operation, the number of deaths and other indicators were compared between groups. Results:In both the two groups of patients who underwent percutaneous transhepatic cholangial drainage, hepatectomy, endoscopic retrograde cholangiopancreatography, hilar cholangiocarcinoma resection and cholecystectomy were mainly performed hepatic artery injury, pancreaticoduodenectomy with gastroduodenal artery injury, and splenectomy with splenic artery injury. In the intervention group, 36 patients (85.7%) were successfully hemostasis after single treatment, and 32 patients (80.0%) in the operation group, and there was no significant difference between the two groups (χ 2=0.47, P=0.492). The first operation time for the intervention group was (40.5±8.5) min and the mortality rate was 2.4% (1/42), which were significantly better than that of the operation group (90.6±20.8) min and 15.0% (6/40) (all P<0.05). Conclusion:Interventional therapy can be used as the first-line diagnosis and treatment for sentinel bleeding after hepatobiliary and pancreatic surgery. It has the advantages of a lower mortality rate in treating these patients.

Clinical effectiveness of endoscopic versus surgical treatment of chronic pancreatitis: a meta-analysis / 中华肝胆外科杂志

Objective:To compare the efficacy of endoscopy and surgery in chronic pancreatitis.Methods:CNKI, CBM, Wanfang, PubMed, Cochrane Library, Embase and Web of Science were searched to compared endoscopy and surgery for the clinical efficacy of chronic pancreatitis. Literatures were searched from the establishment of the database to August 14, 2022. Compared pain relief, clinical response to initial treatment, complications, endocrine/exocrine insufficiency, length of hospital stay and mean number of procedures between the two groups. Manager 5.4.1 software was used for data analysis. Odds ratio ( OR) or weighted mean difference ( WMD) was calculated with 95% confidence interval (95% CI). Results:A total of seven studies were included, including three randomized controlled trials and four retrospective studies with 708 patients. There were 513 males and 195 females. Endoscopic interventions were performed in 364 patients and 344 patients underwent surgery. The results of meta-analysis showed that the total pain relief rate ( OR=0.38, 95% CI: 0.24-0.59) and the complete pain relief rate ( OR=0.47, 95% CI: 0.29-0.77), short-term (1-1.5 years) pain relief rate ( OR=0.42, 95% CI: 0.24-0.74), clinical relief rate ( OR=0.23, 95% CI: 0.10-0.55) were better than the endoscopic group, and could significantly reduce the number of reoperation ( WMD=1.64, 95% CI: 0.89-2.40), and the difference was statistically significant (all P<0.05). There were no significant differences in complications, new-onset endocrine insufficiency, new-onset exocrine insufficiency and length of hospital stay between the endoscopy group and the surgical group (all P>0.05). Conclusion:Surgical intervention is superior to endoscopic treatment in controlling pain associated with chronic pancreatitis and in clinical relief after the first treatment, and can effectively reduce the number of reoperations.

Serum alpha-fetoprotein in predicting survival of patients with BCLC C hepatocellular carcinoma treated by salvage surgery after downstaging therapy / 中华肝胆外科杂志

Objective:To analyze the value of alpha-fetoprotein(AFP) in predicting survival of patients who underwent salvage surgery after tumor downstaging therapy in patients with advanced hepatocellular carcinoma.Methods:The data of 50 patients with Barcelona Clinic Liver Cancer Staging (BCLC) C hepatocellular carcinoma treated at the Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital from December 2018 to December 2021 were collected. There were 45 males and 5 females, with the age of (53.0±10.5) years. The patients were divided into two groups based on the serum AFP level after tumor downstaging therapy, AFP normal group ( n=27, AFP≤20 μg/L) and the control group ( n=23, AFP>20 μg/L). Patient survival and tumor recurrence were followed up by outpatient review or telephone follow-up. The survival rate was calculated by the Kaplan-Meier method and compared by the log-rank test. The efficacy of combined immunotargeted therapy were compared between the two groups. Univariate and multivariate Cox regression analysis were carried to analyse the factors influcing prognosis. Results:The median survival time was not reached in both groups. The 1-year and 2-year cumulative survival rates were 95.0% and 88.2% in the normal group and 73.4% and 54.1% in the control group, respectively. The median relapse-free survival time of the normal group was not reached, and the median relapse-free survival time of the control group was 11 months. The 1-year recurrence-free survival rate was 78.1% in the normal group and 39.5% in the control group. The cumulative survival rate and relapse-free survival rate in the normal group were significantly higher than those in the control group (χ 2=7.60, 8.83, P=0.006, 0.003). The complete response, partial response and pathological complete response of tumors in the normal group were significant better than those in the control group. Multivariate Cox regression analysis showed that patients with serum AFP >20 μg/L ( HR=2.952, 95% CI: 1.023-8.517, P=0.045) after immunotherapy combined with targeted therapy had an increased risk of postoperative recurrence. Conclusion:The reduction of serum AFP to normal after downstaging therapy could be used as a prognostic indicator of salvage surgical in patients with BCLC C hepatocellular carcinoma, and AFP was related to the efficacy of downstaging therapy in patients.

Efficacy of 3D-printed guide plate assisted versus freehand placement of cannulated screws for the treatment of Sanders type II and III calcaneal fractures / 中华创伤杂志

Objective:To compare the efficacy of 3D-printed guide plate assisted versus freehand placement of cannulated screws for the treatment of Sanders type II and III calcaneal fractures.Methods:A retrospective cohort study was conducted to analyze the clinical data of 29 patients with Sanders type II and III calcaneal fractures admitted to Chonggang General Hospital from June 2020 to October 2022. Among them, there were 18 males and 11 females, with an age range of 22-69 years [(40.1±11.5)years]. Nineteen patients were treated with individualized 3D-printed guide plate assisted placement of cannulated screws (3D-printed group) and 10 were treated with freehand placement of cannulated screws (freehand group). The surgical time, fluoroscopy times, postoperative 6-month calcaneal morphology (length, width, height, B?hler angle and Gissane angle), and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Maryland functional score assessed at 3, 6 months after operation and at the final follow-up were compared between the two groups. The incision healing and complications were observed.Results:The patients were followed up for 6-24 months [(11.3±2.5)months]. The surgical time and fluoroscopy times in the 3D-printed group were (53.4±9.1)minutes and (7.3±1.1)times, respectively, which were shorter than (90.2±16.0)minutes and (16.0±3.2)times in the freehand group (all P<0.01). At 6 months after operation, there was no significant difference in calcaneal length between the two groups ( P>0.05); the calcaneal width, height, B?hler angle and Gissane angle in the 3D-printed group [(34.0±1.8)mm, (47.2±1.6)mm, (27.8±1.0)°, (129.2±2.8)°] were superior than those in the freehand group [(37.5±2.0)mm, (43.0±2.7)mm, (25.8±1.5)°, (125.9±2.5)°] (all P<0.01). At 3, 6 months after operation and at the final follow-up, the values of AOFAS ankle-hindfoot score in the 3D-printed group [(72.2±2.3)points, (79.7±2.3)points, (86.5±4.4)points] were higher than those in the freehand group [(64.2±6.9)points, (73.4±4.2)points, (81.8±3.1)points] (all P<0.05); the values of Maryland score in the 3D-printed group [(71.4±7.7)points, (84.7±2.6)points, (91.5±2.5)points] were higher than those in the freehand group [(65.2±5.6)points, (79.1±3.8)points, (87.1±2.9)points] (all P<0.05). All surgical incisions were healed in stage I. In the 3D-printed group, there were no complications regarding infection, iatrogenic vascular or nerve injury, or fixation failure after surgery. In the freehand group, one patient with lateral sural cutaneous nerve injury was resolved spontaneously without specific treatment. Conclusion:Compared with freehand placement of cannulated screws, 3D-printed guide plate assisted placement of percutaneous placement has the advantages of shorter surgical time, fewer fluoroscopy times, lower reduction loss, better ankle joint function recovery, and less complications in treating Sanders type II and III calcaneal fractures.

Issues concerning total knee arthrophlalsty in the treatment of post-traumatic osteoarthritis / 中华创伤杂志

Post-traumatic osteoarthritis (PTOA) refers to the degeneration and destruction of cartilage after trauma to joints and surrounding tissues, along with the damage of subchondral bone, synovium, capsule, muscles and ligaments, finally resulting in osteoarthritis and dysfunction. PTOA of the knee mainly manifests as pain, stiffness and impairment of motion capacity. Management of PTOA includes physical therapy, medication and surgical intervention. Despite the pain was temporarily relieved, the long-term prognosis is still not satisfactory after medication and physical therapy. Surgical intervention is strongly recommended for the moderate and advanced stages of PTOA, which includes arthroscopic debridement, repair of cartilage, osteotomy and arthrodesis. For terminal PTOA, total knee arthroplasty (TKA) is necessary. However, TKA in the treatment of PTOA is challenging, especially for patients with surgical history, poor soft tissue conditions, abnormal alignment, multiple complications, as well as individual variation. Up to now, there is still a lack of standards and consensus for TKA in the treatment of PTOA. Accordingly, the author discusses the issues related to TKA in the treatment of PTOA, aiming to provide a reference for the treatment of PTOA of the knee.

Sponge forceps assisted threading with Speedbridge technique for the treatment of acute closed Achilles tendon rupture / 中华创伤杂志

Objective:To explore the outcome of sponge forceps assisted threading with Speedbridge technique for the treatment of acute closed Achilles tendon rupture.Methods:A retrospective case series study was conducted on 20 patients with acute closed Achilles tendon rupture treated in Zhengzhou Orthopedic Hospital from December 2019 to December 2021. There were 18 males and 2 females, with age range of 24-43 years [(29.5±7.6)years]. All patients were with unilateral injury, involving the left side in 13 patients and right side in 7. Examinations revealed a palpable defect in the Achilles tendon and positive Thompson test. A longitudinal incision was made at the medial edge of the ruptured tendon. Three nonabsorbable sutures were passed through the proximal stump with sponge forceps, bypassed the rupture site and fixed directly into the calcaneal bone. The disrupted tendon ends were aligned by the tendon-bundle technique using 4-0 absorbable sutures. The operation time and incision length were documented. The ankle joint range of motion (dorsiflexion/plantar flexion), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Achilles tendon total rupture score (ATRS) in the affected and healthy side were compared at 3, 6 and 12 months postoperatively. The wound healing and complications were observed.Results:All patients were followed up for 12-16 months [(13.2±2.5)months]. The operation time was 40-66 minutes [(52.0±10.3)minutes], with the incision length of 3-4 cm [(3.3±0.7)cm]. In the affected side at 3 and 6 months postoperatively, the ankle joint dorsiflexion [(5.6±1.5)°, (10.5±0.2)°] and plantar flexion [(28.4±3.2)°, (33.5±1.5)°] showed statistically significant difference compared with the healthy side (all P<0.05). The ankle joint dorsiflexion [(13.9±0.7)°] and plantar flexion [(38.3±4.4)°] in the affected side were not statistically different from that of the healthy side at 12 months postoperatively (all P>0.05). The AOFAS ankle-hindfoot score was (58.3±5.4)points, (84.9±7.1)points and (91.8±6.3)points at 3, 6 and 12 months postoperatively, showing a gradual rise (all P<0.05). The ATRS was (60.5±4.9)points, (85.5±9.0)points and (93.1±5.7)points at 3, 6 and 12 months postoperatively, showing a gradual rise (all P<0.05). All incisions were healed primarily. No patients had wound infection, nerve injury or re-rupture. Pain at the anchor insertion site occurred in 2 patients at 1 month after operation and relieved after active functional rehabilitation at 4 months after operation. Transient pain at the Achilles tendon insertion occurred in 1 patient at 6 months after operation, and relieved after 2 weeks of oral non-steroidal anti-inflammatory drugs treatment. Conclusion:For acute closed Achilles tendon rupture, sponge forceps assisted threading with Speedbridge technique can attain short operation time, small incision and good functional recovery, with few complications.

Chinese expert consensus on emergency surgery for severe trauma and infection prevention during corona virus disease 2019 epidemic (version 2023) / 中华创伤杂志

During coronavirus disease 2019 epidemic, the treatment of severe trauma has been impacted. The Consensus on emergency surgery and infection prevention and control for severe trauma patients with 2019 novel corona virus pneumonia was published online on February 12, 2020, providing a strong guidance for the emergency treatment of severe trauma and the self-protection of medical staffs in the early stage of the epidemic. With the Joint Prevention and Control Mechanism of the State Council renaming "novel coronavirus pneumonia" to "novel coronavirus infection" and the infection being managed with measures against class B infectious diseases since January 8, 2023, the consensus published in 2020 is no longer applicable to the emergency treatment of severe trauma in the new stage of epidemic prevention and control. In this context, led by the Chinese Traumatology Association, Chinese Trauma Surgeon Association, Trauma Medicine Branch of Chinese International Exchange and Promotive Association for Medical and Health Care, and Editorial Board of Chinese Journal of Traumatology, the Chinese expert consensus on emergency surgery for severe trauma and infection prevention during coronavirus disease 2019 epidemic ( version 2023) is formulated to ensure the effectiveness and safety in the treatment of severe trauma in the new stage. Based on the policy of the Joint Prevention and Control Mechanism of the State Council and by using evidence-based medical evidence as well as Delphi expert consultation and voting, 16 recommendations are put forward from the four aspects of the related definitions, infection prevention, preoperative assessment and preparation, emergency operation and postoperative management, hoping to provide a reference for severe trauma care in the new stage of the epidemic prevention and control.

Clinical efficacy of surgical treatment of refractory hyperthyroidism in 56 patients / 中国基层医药

Methods:The clinical data and follow-up results of 56 patients with refractory hyperthyroidism who underwent laparoscopy or open surgery in Affiliated Nanhua Hospital of University of South China from January 2019 to August 2020 were retrospectively analyzed.Results:Among the 56 patients, there were 6 men and 50 women. Thirty-six (64.3%) patients underwent endoscopic surgery and twenty (35.7%) patients underwent open surgery. The operation time was (132.0 ± 32.0) minutes. Intraoperative blood loss was (32.4 ± 27.8) mL. Postoperative parathyroid hormone level was (27.8 ± 18.3) ng/L. Forty-nine (87.5%) patients showed benign pathology results after surgery. After surgery, 14 (25.0%) patients had hypothyroidism, including 7 (12.5%) patients with hyperthyroidism combined with thyroid cancer. There were no patients with permanent hypothyroidism or recurrent laryngeal nerve paralysis. All patients had a good prognosis and satisfactory surgical results.Conclusion:With the update of preoperative preparation methods for hyperthyroidism, the increasing maturity of thyroid surgery technology, and the use of new energy instruments and technologies, surgical treatment is undoubtedly a good treatment method for patients with refractory hyperthyroidism or a suspected malignant tumor.Objevtives:To investigate the indications and clinical efficacy of surgical treatment in patients with refractory hyperthyroidism.

Clinical analysis of 11 cases of iliopsoas muscle hematoma compressing lumbar plexus nerve / 中国基层医药

Objective:To investigate the etiology, clinical manifestations, treatment methods, and prognosis of patients with iliopsoas muscle hematoma compressing the lumbar plexus.Methods:The clinical data of 11 cases of iliopsoas muscle hematoma oppressing the lumbar plexus nerve admitted to The Affiliated Hospital of Southwest Medical University between March 2014 and May 2018 were analyzed.Results:Eleven patients, consisting of 10 men and 1 woman, aged (36.36 ± 6.74) years were analyzed. Causes of iliopsoas muscle hematoma oppressing the lumbar plexus nerve included coagulation abnormality ( n = 8) and trauma ( n = 3). Iliopsoas muscle hematoma occurred on the left side in 7 cases and on the right side in 4 cases. Among them, 11 cases had bleeding in the middle area, 8 cases in the lower area, and 2 cases in the upper area. The involved lumbar plexus nerve included the femoral nerve ( n = 11), lateral femoral cutaneous nerve ( n = 6), and obturator nerve ( n = 2). Eleven cases underwent causative treatment ( n = 11). Three-month follow-up results showed that the hematomas were completely absorbed in 11 cases, and the bone and joint activities were normal. The sensory and motor functions were restored in 10 cases. The sensory function was restored, but the recovery of motor function was poor in 1 patient. All 11 cases returned to normal after 1 year. Conclusion:The main causes of iliopsoas muscle hematoma are coagulation dysfunction and trauma. The femoral nerve and lateral femoral cutaneous nerve in the lumbar plexus are easily affected, which can cause lower limb sensory and motor disorders. As for iliopsoas muscle hematoma caused by coagulation abnormality, coagulation factors should be supplemented to correct coagulation function. As for iliopsoas muscle hematoma caused by trauma, early surgical treatment should be performed to relieve nerve compression. Timely treatment of iliopsoas muscle hematoma can generally acquire a good prognosis.

Risk factors for pulmonary infection after laparoscopic surgery in treatment of hepatocellular carcinoma with liver cirrhosis and portal hypertension / 临床肝胆病杂志

Objective To investigate the incidence rate of pulmonary infection after laparoscopic surgery and related risk factors in patients with hepatocellular carcinoma (HCC) comorbid with liver cirrhosis and portal hypertension (PHT). Methods A retrospective analysis was performed for the clinical data of 105 HCC patients with liver cirrhosis and PHT who underwent laparoscopic surgery in Beijing Ditan Hospital, Capital Medical University, from January 2017 to February 2022. A total of 30 factors that might cause pulmonary infection were recorded, including general information, disease factors, surgical factors, and postoperative factors. Postoperative recovery was observed and the occurrence of pulmonary infection was recorded. The chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups, and the multivariate logistic regression analysis was used to investigate the independent risk factors for pulmonary infection. Results Among the 105 patients, 66 underwent laparoscopic devascularization combined with hepatectomy and 39 underwent laparoscopic devascularization combined with radiofrequency ablation (RFA). The surgery was successful for all patients, with no case of conversion to laparotomy or unscheduled reoperation. No death was observed within 30 days after surgery and during hospitalization, with a median length of hospital stay of 20 days (range 14-25 days). The incidence rate of pulmonary infection was 25.71% (27/105). Smoking (odds ratio [ OR ]=3.362, 95% confidence interval [ CI ]: 1.282-8.817, P =0.014), MELD score ( OR =3.801, 95% CI : 1.007-14.351, P =0.049), tumor location ( OR =1.937, 95% CI : 1.169-3.211, P =0.010), surgical procedure ( OR =0.006, 95% CI : 0.001-0.064, P =0.000), intraoperative infusion volume ( OR =4.871, 95% CI : 1.211-19.597, P =0.026), and postoperative pleural effusion ( OR =9.790, 95% CI : 1.826-52.480, P =0.008) were independent risk factors for pulmonary infection. Conclusion There is a relatively high risk of pulmonary infection in HCC patients with liver cirrhosis and PHT undergoing laparoscopic surgery. Postoperative pleural effusion is the high risk factor for pulmonary infection, and devascularization combined with RFA can significantly reduce the risk of pulmonary infection. It is recommended to strengthen preoperative rehabilitation, perioperative liver function maintenance, intraoperative damage control, and goal-oriented fluid therapy and reduce postoperative fluid accumulation in the third space, so as to reduce the incidence rate of pulmonary infection.

Efficacy of different laparoscopic surgeries for gastrointestinal stromal tumors of gastric cardia and fundus: a multicenter study / 中华消化外科杂志

Objective:To investigate the efficacy of different laparoscopic surgeries for gastrointestinal stromal tumors (GIST) of gastric cardia and fundus.Methods:The retrospective cohort study was conducted. The clinicopathological data of 251 patients with GIST of gastric cardia and fundus who underwent laparoscopic radical resection in 14 medical centers, including Guangdong Provincial People′s Hospital et al, from December 2007 to December 2021 were collected. There were 123 males and 128 females, aged 58(24,87)years. Observation indicators: (1) treatment; (2) clinicopathological data of patients undergoing different laparoscopic surgeries; (3) subgroup analysis for special laparoscopic techniques. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test or ANOVA. Measure-ment data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the Mann-Whitney U test or Kruskal-Wallis H test. Count data were described as absolute numbers or percentages. Comparison of ordinal data was conducted using the rank sum test. Results:(1) Treatment. Of the 251 patients,202 cases underwent gastric wedge resection, 26 cases underwent special laparoscopic techniques including 10 cases with serotomy and dissection and 16 cases with transluminal gastrectomy, 23 cases underwent structural gastrectomy including 6 cases with total gastrectomy and 17 cases with proximal partial gastrectomy. There were 24 patients had postoperative complications after surgery. (2) Clinicopathological data of patients undergoing different laparoscopic surgeries. The gender (male, female), age, tumor diameter, operation time, volume of intraoperative blood loss, length of incision, time to postoperative initial whole liquid food intake, time to postoperative initial semi-liquid food intake, duration of postoperative hospital stay, cases with perioperative complications, cases with mitotic count as ≤5/50 high power field, 6?10/50 high power field, >10/50 high power field, cases be classified as very low risk, low risk, medium risk, high risk according to the National Institutes of Health risk classification, cases with tumor located at fundus and gastric cardia were 93, 109, (59±11)years, 3.50(0.40,10.00)cm, 88.00(25.00,290.00)minutes,20.00(25.00,290.00)mL, 4.00(2.00,12.00)cm, 3.00(1.00,9.00)days, 4.00(1.00,16.00)days, 5.00(1.00,18.00)days, 14, 164, 31, 7, 47, 83, 50, 22, 30, 172 in patients undergoing gastric wedge resection, respectively. The above indicators were 19, 7, (49±14)years, 2.55(0.20,5.00)cm, 101.00(59.00,330.00)minutes, 27.50(2.00,300.00)mL, 4.50(0,6.00)cm, 2.50(1.00,10.00)days, 4.00(1.00,16.00)days, 6.00(1.00,18.00)days, 3, 20, 5, 1, 15, 5, 2, 4, 24, 2 in patients undergoing special laparos-copic techniques, and 11, 12, (52±10)years, 5.00(0.80,10.00)cm, 187.00(80.00,325.00)minutes, 50.00(10.00,300.00)mL, 6.00(4.00,12.00)cm, 4.00(2.00,8.00)days, 6.00(3.00,14.00)days, 8.00(2.00,18.00)days, 7, 11, 5, 7, 2, 6, 6, 9, 13, 10 in patients undergoing structural gastrectomy. There were significant differences in the above indicators among the three groups of patients ( χ2=6.75, F=10.19, H=17.71, 37.50, 35.54, 24.68, 16.09,20.20, 13.76, χ2=13.32, Z=28.98, 32.17, χ2=82.14, P<0.05). (3) Subgroup analysis for special laparoscopic techniques. The time to postoperative initial whole liquid food intake, time to postoperative initial semi-liquid food intake, classification of tumor location (endophytic type, exophytic type, parietal type) were 4.50(1.00,10.00)days, 8.00(3.00,12.00)days, 0, 8, 2 in patients undergoing serotomy and dissection, versus 2.00(1.00,4.00)days, 3.00(1.00,6.00)days, 16, 0, 0 in patients undergoing transluminal gastrectomy. There were significant differences in time to postoperative initial whole liquid food intake, time to postoperative initial semi-liquid food intake between them ( Z=-2.65, -3.16, P<0.05); and there was a significant difference in classification of tumor location between them ( P<0.05). Conclusions:Gastric wedge resection is the most commonly used laparoscopic technique for GIST of gastric cardia and fundus. The application of special laparoscopic techniques is focused on the GIST of cardia to preserve the function of the cardia.