Primary versus Flap Closure of Perineal Defects following Oncologic Resection: A Systematic Review and Meta-Analysis.

BACKGROUND: Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to compare primary closure with myocutaneous flap reconstruction of perineal defects following abdominoperineal resection or pelvic exenteration with regard to surgical-site complications. METHODS: A comprehensive literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the MEDLINE, EMBASE, Google Scholar, and Cochrane Library databases. After data extraction from included studies, meta-analysis was performed to compare outcome parameters defining surgical-site complications of flap and primary closure. RESULTS: Our systematic review yielded 10 eligible studies (one randomized controlled trial and nine retrospective studies) involving 566 patients (226 flaps and 340 primary closures). Eight studies described rectus abdominis myocutaneous flaps and two studies used gracilis flaps. In meta-analysis, primary closure was more than twice as likely to be associated with total perineal wound complications compared with flap closure (OR, 2.17; 95 percent CI, 1.34 to 3.14; p = 0.001). Rates of major perineal wound complications were also significantly higher in the primary closure group (OR, 3.64; 95 percent CI, 1.43 to 7.79; p = 0.005). There was no statistically significant difference between primary and flap closure for minor perineal wound complications, abdominal hernias, length of stay, or reoperation rate. CONCLUSIONS: This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure for pelvic reconstruction. The authors' results have validated the use of myocutaneous flaps for reducing perineal morbidity following abdominoperineal resection or pelvic exenteration. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Communication about maternal-fetal surgery for myelomeningocele and congenital diaphragmatic hernia: preliminary findings with implications for informed consent and shared decision-making.

OBJECTIVE: To examine the style and content of consultations for maternal-fetal surgery and draw conclusions about best practices for informed consent and shared decision-making. STUDY DESIGN: Qualitative study of 15 h-long consultations with women diagnosed with fetal myelomeningocele (MMC, n=11) or congenital diaphragmatic hernia (CDH, n=4) who were potential candidates for maternal-fetal surgery at a large children's hospital in the Southwestern US. RESULTS: Major findings were that physicians tended to discuss the risks of fetal prognosis qualitatively more often than quantitatively (70% compared to 30%) and when mortality was a risk the "positive" (percentage survival) frame was always given rather than the morality frame. On average, families only talked 15% of the time and 45% of all their questions were about diagnostic or surgical procedure clarification. CONCLUSION: Efforts should be made to minimize qualitative presentation of risk, which can be vague and confusing to patients. Both survival and mortality frames should be used to avoid biased decision-making. Communication and decision support tools that facilitate more shared decision-making between families and physicians are needed.

Does perioperative steroid use improve clinical outcomes in open repair of craniosynostosis?

BACKGROUND: The benefits of routine perioperative steroid use to decrease facial edema, ecchymosis, pain, and reduced length of hospitalization have been reported for many procedures. The role of perioperative steroids after open craniosynostosis surgery remains understudied. The purpose of our study was to assess the safety and efficacy of perioperative steroid administration in open repair of craniosynostosis based on current published clinical evidence. METHODS: A systematic review of PubMed, EMBASE, ClinicalTrials.gov, and the Cochrane library databases using inclusion and exclusion criteria was performed for articles that studied the efficacy of perioperative steroid use in craniosynostosis patients receiving open cranial repair surgery. RESULTS: Our review yielded 149 unique citations. One hundred thirty-nine titles were excluded based on predefined criteria. Ten abstracts and 4 articles (n = 14) qualified for full-text screening. Two additional relevant articles were identified using references. Three observational studies were eligible for data abstraction. A Cohen κ coefficient score of 0.88 demonstrated high interrater agreement throughout the screening process. Clinical benefits in this specific population observed were improved control of postoperative edema, earlier time to eye opening, and reduced length of hospital stay. The timing, method, and technique of steroid administration varied between studies. CONCLUSIONS: The reviewed literature supports a clinical benefit following administration of perioperative steroids for open repair surgery of craniosynostosis. However, the current level of evidence on safety and efficacy remains limited in rigor and volume. Further randomized trials are necessary prior to recommending routine steroid use in our study population. CLINICAL QUESTION/LEVEL OF EVIDENCE: therapeutic, level III.

Evaluation of a none compressed 12-lead ECG transmission via internet using IPSec.

Electrocardiogram (ECG) transmission in real time could involve some problems with the quality of services and security. This paper aims to evaluate a none compressed 12-lead ECG transmission using the Secure Internet Protocol (IPSec), compared with the popular Internet Protocol (IP). Using an analytical model, the transmission performance is estimated in terms of end-to-end delay and loss rate. Our results show that ECG transmission could be assured both security and quality of services.