Short-term outcomes of traction-assisted versus conventional endoscopic submucosal dissection for superficial gastrointestinal neoplasms: a systematic review and meta-analysis of randomized controlled studies.

BACKGROUND: In recent years, some traction-assisted approaches have been introduced to facilitate endoscopic submucosal dissection (ESD) procedures by reducing the procedure time and risks related to the procedure. However, the relative advantages of traction-assisted endoscopic submucosal dissection (T-ESD) are still being debated. This study aimed to assess the efficacy of T-ESD for the treatment of superficial gastrointestinal neoplasms. METHODS: We searched MEDLINE, Embase, and Cochrane library up to March 31, 2019 for randomized controlled trials (RCTs) comparing T-ESD and conventional endoscopic submucosal dissection (C-ESD) for superficial gastrointestinal neoplasms. The main endpoints are en bloc resection, complete resection, procedure time, perforation, and delayed bleeding. Pooled risk ratio (RR), Peto odds ratio (OR), and mean difference (MD) were calculated to compare T-ESD and C-ESD. This study is registered with PROSPERO, number CRD42018108135. RESULTS: A total of 7 RCTs with 1007 patients were included in this meta-analysis. There were no significant differences between the T-ESD and C-ESD groups in the pooled estimate of en bloc resection, complete resection, and delayed bleeding (RR = 1.00, 95% CI 0.99, 1.01, I2 = 0%, P = 0.66; RR = 1.00, 95% CI 0.98, 1.03, I2 = 0%, P = 0.81; OR = 0.95, 95% CI 0.48, 1.86, I2 = 19%, P = 0.87,respectively). The pooled estimate indicated that the procedure time was significantly shorter in the T-ESD group (MD = - 16.19, 95% CI - 29.24, - 3.13, I2 = 87%, P = 0.02) than in the C-ESD group. Compared to C-ESD, T-ESD was associated with lower incidence of perforation (OR = 0.32, 95% CI 0.11, 0.91, I2 = 0%, P = 0.03). CONCLUSIONS: T-ESD is a safe and effective treatment option with a low perforation rate and shorter procedure time than C-ESD for superficial gastrointestinal neoplasms. Future multi-center (including European populations), randomized controlled trials of larger sample size and long-term outcomes of T-ESD are required.

Decapitación intraparto. Análisis de un caso excepcional / Intrapartum decapitation of the newborn. An unusual case

Durante un parto que se desarrollaba normalmente, al efectuar maniobras habituales de tracción cefálica, la obstetra fue sorprendida por la decapitación fetal. El informe de autopsia inculpó a la obstetra, y el patólogo atribuyó el hecho a una tracción excesiva y brutal a dicha profesional. Un análisis de las anotaciones en la historia clínica permitió encontrar la causa de este hecho inusual y liberar a dicha obstetra de toda responsabilidad

During a presumable normal labor and delivery, while tractioning the fetus as usual, the doctor midwife was suddenly surprised by fetal decapitation and found herself holding the baby's head in her hands. The coroner, in a very subjective evaluation of the facts, indicted the midwife, accusing her of applying unusual and brutal forces to disengage the fetus to accomplish the delivery. He even coined the word "brutalectomy" to describe the situation. A careful analysis of the medical record revealed the most plausible explanation of this unusual event

High morbidity and mortality after lower extremity injuries in Malawi: A prospective cohort study of 905 patients.

INTRODUCTION: A lower extremity injury can be a devastating event in low-income countries due to limited access to surgical care. Its incidence, treatment patterns, and outcomes, however, have not been well-described. METHODS: We prospectively enrolled all patients admitted with lower extremity trauma to a tertiary hospital in Lilongwe, Malawi between October 2010 and September 2011. Patients with a lower extremity injury but primarily admitted for unrelated reasons were excluded. The outcomes were deaths, complications, and length of hospital stay. RESULTS: Of the 905 patients eligible for analysis, 696 (77%) were males. Most patients had femur fractures (46%), and most were treated non-operatively (70%). Overall mortality rate was 3.9%. For adult patients with femur fractures, mortality was higher in patients treated with traction (9.0%) than for those treated with surgery (1.3%). The total complication rate was 15%, with adjusted odds of developing a complication higher in patients with concurrent head injury (OR = 2.8; 95% CI: 1.3-6.0), and patients who had an operative treatment (OR = 2; 95% CI: 1.2-1.9). The median length of stay was 16 days (IQR: 6-27) and was greatest among patients with femur fractures. CONCLUSION: Lower extremity injuries resulted in substantial mortality and morbidity in this low-income country. Mortality was particularly high among patients with femur fractures who did not have surgery. Modern orthopedic trauma surgery is greatly needed in low-income countries.

Open abdomen treatment after aortic aneurysm repair with vacuum-assisted wound closure and mesh-mediated fascial traction.

OBJECTIVES: Open abdomen (OA) treatment is sometimes necessary after surgery for aortic aneurysm (AA), to prevent or treat abdominal compartment syndrome (ACS). A multicentre study evaluating vacuum-assisted wound closure (100-150 mmHg) and mesh-mediated fascial traction (VAWCM) was performed. METHODS: All patients treated with OA after AA repair (2006-2009) were prospectively registered at four centres; those treated <5 days were excluded. All surviving patients underwent a 1-year follow-up, including computed tomography (CT) examination. RESULTS: Among 1041 patients treated with open or endovascular repair of AA, 28 (2.9%) had OA treatment with VAWCM; another two had VAWCM after hybrid operations for thoraco-abdominal AA. Eighteen (60%) were operated on for rupture and 12 (40%) electively. Eight had suprarenal or thoraco-abdominal aneurysms. Eight (27%) died within 30 days, none due to OA-related complications. Four died before abdominal closure; primary delayed fascial closure was achieved in all survivors. One-year mortality was 50%. Ten (33%) had bowel ischaemia requiring bowel resection. Late potential OA-related infectious complications occurred in five (17%), all of whom first developed intestinal ischaemia: entero-atmospheric fistulae (two), graft infections (two), aorto-enteric fistula (one). One year follow-up with clinical evaluation and CT showed no signs of graft infection. Incisional hernias occurred in 9 of 15 patients (60%); only three were symptomatic. CONCLUSION: VAWCM provided high fascial closure rate after AA repair and long-term OA treatment. Infectious complications occur after intestinal ischaemia and prolonged OA treatment, and are often fatal. The poor prognosis among patients needing OA after AA surgery may be improved by using VAWCM, permitting earlier closure.

One-year outcome for elderly patients with displaced intracapsular fractures of the femoral neck managed non-operatively.

The outcome of patients with a displaced intracapsular femoral neck fracture treated non-operatively was assessed at 1 year and compared with patients managed operatively over the same time period. Data were collected prospectively for 102 consecutive patients. 80 patients underwent hemiarthroplasty and 22 were managed non-operatively. Patients were managed non-operatively if they were felt to have an unacceptably high risk of death within the perioperative period despite medical optimisation. Non-operative management entailed active early mobilisation without bed rest or traction. Patients managed non-operatively had a greater 30-day mortality compared with operatively managed patients. Deaths were due to pre-existing medical conditions or events, which had occurred at the time of hip fracture. No patient in the non-operative treatment group developed pneumonia, pressure sores or thrombo-embolic events. Patients treated non-operatively, who survived 30 days after fracture, had a mortality rate over the following year comparable with those who had undergone surgery. At 1 year, all non-operatively managed patients were able to transfer without pain and 6 of the 11 surviving patients were able to mobilise with walking aids. At 1 year, the majority of surviving non-operatively managed patients were living in their own homes. Surgical intervention is the treatment of choice for the majority of elderly patients with a displaced intracapsular femoral neck fracture. However, in patients with life-threatening medical co-morbidity, non-operative treatment with early mobilisation can yield acceptable results.

Early results after treatment of open abdomen after aortic surgery with mesh traction and vacuum-assisted wound closure.

OBJECTIVES: This study aimed to describe the use of vacuum-assisted wound closure (VAWC) and mesh traction to repair an open abdomen after aortic surgery. DESIGN: Prospective clinical study. MATERIAL AND METHODS: From October 2006 to April 2009, nine consecutive patients were treated; seven of the patients received laparostomy following abdominal compartment syndrome (ACS), while two wounds were left open initially. The indication for laparostomy was intra-abdominal pressure (IAP) > 20 mmHg or abdominal perfusion pressure (APP) < 60 mmHg and development of organ failure. V.A.C. therapy (KCI, San Antonio, TX, USA) was initiated with the laparostomy, and supplemented with a fascial mesh after 2 days. The wound was then closed stepwise with mesh traction and VAWC. RESULTS: All wounds could be closed following a median interval of 10.5 (range: 6-19) days after laparostomy. A median of four (range: 2-7) dressing changes were performed. One patient died on the seventh postoperative day. Two other patients died 38 and 50 days after final closure, respectively. Left colonic necrosis was seen in two patients while incisional hernia was observed in two patients. Mean follow-up duration was 17 (range: 2-36) months. CONCLUSION: VAWC with mesh traction was successful in terms of early delayed primary closure and is a useful tool in the treatment of open abdomen after aortic surgery.