Comparisons of medicinal leech therapy with venous catheterization in the treatment of venous congestion of the sural flap

Introduction: The originally described distally based sural flap technique has a risk of partial or total flap necrosis as high as 25%. The purpose of this study was to compare the medicinal leech therapy (MLT) with venous catheterization (VC) for blood volume removal, infection, wound dehiscence, and flap necrosis in the distally based sural flap with venous congestion. Patients and methods: Fifty‐six conventional distally based sural flaps with venous congestion during reconstructive surgeries were randomly divided into two groups, MLT group and VC group. The results of comparisons were analyzed using SPSS software (SPSS for Windows Ver.11.5). Results: There were significant differences in terms of the average volume of removed blood (53.6cc vs.172.2cc), infection (10.7% vs. 34.6%), wound dehiscence (10.7% vs. 42.3%), flap necrosis (3.6% vs. 19.2%), and nursing (7.8 vs. 5.19) and patient's satisfaction (8.03 vs. 5.6) in the VC group and MLT group, respectively. Although local heparin irrigation was performed in the VC group, the catheter was exchanged in 10 patients due to obstruction by clot. Conclusion: It is recommended that the VC be used for congested pedicled flaps instead of leech therapy, as VC is more effective, easy, and safe in blood removal, and it has less complication. © 2010 Wiley‐Liss, Inc. Microsurgery, 2011.     

Laser and light-based therapies in the management of rosacea: an updated systematic review

Lasers in Medical Science - Unlike other rosacea therapies which need daily takings or applications over long periods, the edge of lasers and light-based therapies (LLBT) is the limited number of...     

Balloon kyphoplasty in the management of vertebral compression fractures: an updated systematic review and meta-analysis

This systematic review updates the understanding of the evidence base for balloon kyphoplasty (BKP) in the management of vertebral compression fractures. Detailed searches of a number of electronic databases were performed from March to April 2006. Citation searches of included studies were undertaken and no language restrictions were applied. All controlled and uncontrolled studies were included with the exception of case reports. Prognostic factors responsible for pain relief and cement leakage were examined using meta-regression. Combined with previous evidence, a total of eight comparative studies (three against conventional medical therapy and five against vertebroplasty) and 35 case series were identified. The majority of studies were undertaken in older women with osteoporotic vertebral compression fractures with long-term pain that was refractory to medical treatment. In direct comparison to conventional medical management, patients undergoing BKP experienced superior improvements in pain, functionality, vertebral height and kyphotic angle at least up to 3-years postprocedure. Reductions in pain with BKP appeared to be greatest in patients with newer fractures. Uncontrolled studies suggest gains in health-related quality of life at 6 and 12-months following BKP. Although associated with a finite level of cement leakage, serious adverse events appear to be rare. Osteoporotic vertebral compression fractures appear to be associated with a higher level of cement leakage following BKP than non-osteoporotic vertebral compression fractures. In conclusion, there are now prospective studies of low bias, with follow-up of 12 months or more, which demonstrate balloon kyphoplasty to be more effective than medical management of osteoporotic vertebral compression fractures and as least as effective as vertebroplasty. Results from ongoing RCTs will provide further information in the near future. This report has been undertaken through unrestricted funding by Kyphon Inc. The planning, conduct and conclusions of this report are made independently from the company.     

Diverticulitis of the colon: Clinical review of acute presentations and management

A series of 46 patients treated surgically for acute sequelae of diverticular disease of the colon was reviewed. Perforation of sigmoid diverticulitis and colon obstruction were the most common indications for surgical treatment. Resection of the involved colon was carried out in 44 of 46 patients. Primary resection was performed in 27 patients and primary anastomosis was achieved in 19 of these. Staged resections were employed in 17 patients. The mortality rate was 4.4 percent and the complication rate 28.3 percent. Some suggestions are made in an effort to decrease morbidity in the future.     

Screening for prostate cancer: an updated Cochrane systematic review

OBJECTIVE

? To determine whether screening for prostate cancer reduces prostate cancer‐specific mortality, impact on all‐cause mortality and patient health‐related quality of life.

MATERIALS AND METHODS

? An update to our 2006 Cochrane systematic review was performed by re‐running an updated search of several databases, including MEDLINE and the Cochrane CENTRAL Register of Controlled Trials. ? Articles were included if they were a randomized controlled trial (RCT) examining screening vs no screening for prostate cancer. Data was collected and analysed according to the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

? Five RCTs with a total of 341 351 participants were included in this updated Cochrane systematic review. All involved PSA testing, although the interval and threshold for further evaluation varied across trials. The age of participants was 50–74 years, with durations of patient follow‐up of 7–15 years. ? The methodological quality of three of the studies was assessed as posing a high risk of bias. ? Meta‐analysis of the five included studies indicated no statistically significant difference in prostate cancer‐specific mortality between men randomized to screening and control [relative risk (RR) 0.95, 95% CI 0.85–1.07]. Sub‐group analyses indicated that prostate cancer‐specific mortality was not affected by age at which participants were screened. A pre‐planned analysis of a ‘core’ age group of men aged 55–69 years from the largest RCT (European Randomised Study of Screening for Prostate Cancer) reported a significant 20% relative reduction in prostate cancer‐specific mortality; (95% CI 0.65–0.98; absolute risk 0.71 per 1000 men). The number of men diagnosed with prostate cancer was significantly greater in men randomized to screening, compared with those randomized to control (RR 1.35, 95% CI 1.06–1.72). ? Harms of screening included high rates of false‐positive results for the PSA test, over‐diagnosis and adverse events associated with transrectal ultrasonography guided biopsies such as infection, bleeding and pain.

CONCLUSIONS

? Prostate cancer screening did not significantly decrease all‐cause or prostate cancer‐specific mortality in a combined meta‐analysis of five RCTs. ? Any benefits from prostate cancer screening may take >10 years to accrue; therefore, men who have a life expectancy of <10–15 years should be informed that screening for prostate cancer is not beneficial and has harms.     

Minimally invasive esophagectomy for esophageal cancer: an updated review

Purpose

The surgical, postoperative and oncologic outcomes of minimally invasive esophagectomy (MIE) for esophageal cancer were reviewed to clarify the benefits of this surgical modality.

Methods

A systematic literature search was performed using synonyms for minimally invasive or thoracoscopic esophagectomy. There were 18 retrospective cohort studies and 3 meta-analyses retrieved in this review.

Results

There are several minimally invasive approaches for esophageal cancer. Total MIE using both the thoracoscopic and laparoscopic approach is increasingly performed. A longer operative time and less blood loss are observed with MIE in comparison to open esophagectomy (OE). Although the benefit of MIE for reducing morbidity and mortality rates is still under debate, a shorter hospital stay was common among the studies. The oncologic outcomes of MIE were not inferior to OE, while the number of retrieved lymph nodes was greater in MIE than OE in several studies.

Conclusion

Total MIE using a combined thoracoscopic and laparoscopic approach can be performed safely, although the benefits for short-term outcomes are still controversial. Oncologic outcomes are favorable and MIE may have an advantage in lymph node dissection over OE. The benefits of MIE should therefore be confirmed by randomized controlled trials.     

Therapeutic apheresis in kidney diseases: an updated review

Besides conventional medical therapies, therapeutic apheresis has become an important adjunctive or alternative therapeutic option to immunosuppressive agents for primary or secondary kidney diseases and kidney transplantation. The available therapeutic apheresis techniques used in kidney diseases, including plasma exchange, double-filtration plasmapheresis, immunoadsorption, and low-density lipoprotein apheresis. Plasma exchange is still the leading extracorporeal therapy. Recently, growing evidence supports the potential benefits of double-filtration plasmapheresis and immunoadsorption for more specific and effective clearance of pathogenic antibodies with fewer side effects. However, more randomized controlled trials are still needed. Low-density lipoprotein apheresis is also an important supplementary therapy used in patients with recurrent focal segmental glomerulosclerosis. This review collects the latest evidence from recent studies, focuses on the specific advantages and disadvantages of these techniques, and compares the discrepancy among them to determine the optimal therapeutic regimens for certain kidney diseases.     

Effect of dexmedetomidine for prevention of acute kidney injury after cardiac surgery: an updated systematic review and meta-analysis

BackgroundAcute kidney injury (AKI) is a serious complication related to cardiac surgery. Several studies have been conducted to investigate the effect of dexmedetomidine administration on AKI prevention.ObjectiveTo assess if dexmedetomidine is associated with a protective effect of renal function after cardiac surgery. And the aim of conducting this meta-analysis is to summarize the literature and determine the clinical utility of dexmedetomidine administration in patients undergoing cardiac surgery.MethodsPubMed, Cochrane Library, and EMBASE databases were comprehensively searched for all randomized controlled trials (RCTs) published before 1 December, 2021 that investigated the effect of dexmedetomidine on AKI prevention.ResultsOur analysis included 16 studies involving 2148 patients. Compared with the control group, dexmedetomidine administration significantly reduced AKI incidence (OR, 0.47; 95% CI, 0.36–0.61; p <  0.00001; I² = 26%) and the length of stay in the intensive care unit (ICU) but did not alter mortality rate, length of stay in the hospital, and mechanical ventilation time. Furthermore, the incidence of delirium among patients treated with dexmedetomidine was significantly decreased.ConclusionDexmedetomidine administration has a positive effect on preventing AKI and postoperative delirium after cardiac surgery and significantly reduces the length of stay in the ICU.     

An updated review on the principles of intraoperative neurophysiological monitoring and the anaesthetic considerations

It is known that any surgery to the nervous system poses risks to neural structures and their surrounding structures. These mechanisms of injury are the result of mechanical manipulations, haemodynamic alterations, chemical or thermal injuries. Intraoperative neurophysiological monitoring (IONM), using various modalities, is employed to facilitate the assessment of the functional integrity of neural structures, and it is used to provide a real-time alerting system when changes caused by surgically induced insults are detected. The primary goal of IONM is reducing the risk of postoperative neurological deficits during these surgical procedures. It is used to provide information that allows the surgeon to correct any surgical interventions that may have compromised these systems and this also in turn provides guidance on what neurological deficits to anticipate postoperatively. Apart from being utilized as an alerting system to avoid catastrophic outcomes, IONM also assists as a guidance system using stimulation techniques to map out eloquent areas within the cortex, allowing identification of specific neuronal structures, particularly when landmarks cannot be easily recognized due to infiltration by pathological lesions.In this article, we focus on updating our previous paper published in 2019 and again, to provide attention to the various neurophysiological modalities that are employed in IONM. We will look at the basic underlying physiological principles and their individual indications for use clinically. We will explain the information that each modality provides. Importantly, and the primary reason for this article, we look at the various anaesthetic agents, their effects on each neurophysiological modality and other anaesthetic considerations such as haemodynamic and temperature effects. We will also recommend the use of an alert checklist for the multidisciplinary team should an intraoperative alert be issued during surgical procedures.     

Clinical outcome of single-incision slings,excluding TVT-Secur,vs standard slings in the surgical management of stress incontinence: an updated systematic review and meta-analysis

The aim of the present paper was to assess and compare the long-term efficacy and safety of single-incision mini-slings (SIMSs), except tension-free vaginal tape (TVT)-Secur, with standard midurethral slings (SMUSs) for female stress urinary incontinence through an updated systematic review and meta-analysis of randomized controlled trials (RCTs) comparing these two surgical methods. A literature review of all RCTs comparing SIMSs (Mini-Arc, Contasure-Needleless, Ophira, Tissue Fixation System and Ajust), except TVT-Secur, with SMUSs was performed. The Medline, Embase, Scopus, Web of Science and Cochrane Controlled Trial Register databases were reviewed. We retrieved 29 RCTs (including a total of 2 986 patients) that compared SIMSs, except TVT-Secur, with SMUSs. Meta-analysis of long-term results showed no significant difference in the patient-reported cure rate (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.44–1.60); however, we found that SMUSs had a significantly superior objective cure rate (OR 0.68, 95% CI 0.47–0.99; P = 0.04). SIMSs were associated with a significantly shorter operation time, lower immediate postoperative pain based on a visual analogue scale score, lower intra-operative blood loss, and lower postoperative voiding dysfunction. The meta-analysis showed clear evidence of the superiority of SMUSs over SIMSs, except TVT-Secur, in terms of the objective cure rate, after long-term follow-up; however, SIMSs were superior with respect to immediate postoperative pain, intra-operative blood loss, and postoperative voiding dysfunction.     

The basilic vein: an alternative drainage of DIEP flap in severe venous congestion

The deep inferior epigastric perforator (DIEP) flap has become a major advance in autologous breast reconstruction, offering all the advantages of free TRAM flap with less donor-site morbidity and postoperative pain. The major drawback threatening the DIEP flap procedure is venous congestion, with potential partial or complete flap loss. Many authors reported different surgical tips aiming to solve this setback, including secondary anastomosis of deep inferior superficial epigastric vein with alternative venous outflow vessels. We present a case report of a DIEP flap salvaged by an alternative venous anastomosis, after comitant veins of the primary anastomosis widely thrombosed a few hours postoperatively. A venous bypass using ipsilateral basilica vein and superficial inferior epigastric vein was fashioned.     

Chemical and mechanical alternatives to leech therapy: a systematic review and critical appraisal

Although leech therapy is a well-established, effective method of relieving venous congestion, it is associated with complications such as wound infection and leech migration. To minimize these risks, efforts to reproduce their effects have been developed and investigated. A search string using (chemical OR mechanical OR alternative) AND (Leeches OR HIRUDO MEDICINALIS) in Boolean format was used across the major electronic databases to cover the past 10 years. Selected references were subsequently validated against critical appraisal frameworks and classified and evaluated against a framework of hierarchies of evidence. Out of 95 retrieved studies, 25 articles were selected after content appraisal. Of these, 12 articles were methodologically and statistically robust. The heterogeneity noted in the studies precluded meta-analysis of the results. The studies infer evidence at Grade B level that current device prototypes show proof of concept by providing suction and chemical anticoagulation following a surgically created wound. Although progress had been made to replicate leech action, there are still areas to address in future research. This article represents the current state of play in clinical translation of these concepts, providing efficacious devices without the drawbacks of traditional leech therapy.