Cell salvage in emergency trauma surgery.

BACKGROUND: Trauma is the leading cause of death in people under the age of 45 years. Over the past 20 years, intraoperative autologous transfusions (obtained by cell salvage, also known as intraoperative blood salvage (IBS)) have been used as an alternative to blood products from other individuals during surgery because of the risk of transfusion-related infections such as hepatitis and human immunodeficiency virus (HIV). In this review, we sought to assess the effects and cost of cell salvage in individuals undergoing abdominal or thoracic surgery. OBJECTIVES: To compare the effect and cost of cell salvage with those of standard care in individuals undergoing abdominal or thoracic trauma surgery. SEARCH METHODS: We ran the search on 25 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid OLDMEDLINE, EMBASE Classic + EMBASE (OvidSP), PubMed, and ISI Web of Science (SCI-Expanded & CPSI-SSH). We also screened reference lists and contacted principal investigators. SELECTION CRITERIA: Randomised controlled trials comparing cell salvage with no cell salvage (standard care) in individuals undergoing abdominal or thoracic trauma surgery. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data from the trial reports. We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: Only one small study (n = 44) fulfilled the inclusion criteria. Results suggested that cell salvage did not affect mortality overall (death rates were 67% (14/21 participants) in the cell salvage group and 65% (15/23) in the control group) (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.31 to 3.72). For individuals with abdominal injury, mortality was also similar in both groups (OR 0.48, 95% CI 0.11 to 2.10).Less donor blood was needed for transfusion within the first 24 hours postinjury in the cell salvage group compared with the control group (mean difference (MD) -4.70 units, 95% CI -8.09 to -1.31). Adverse events, notably postoperative sepsis, did not differ between groups (OR 0.54, 95% CI 0.11 to 2.55). Cost did not notably differ between groups (MD -177.81, 95% CI -452.85 to 97.23, measured in GBP in 2002). AUTHORS' CONCLUSIONS: Evidence for the use of cell salvage in individuals undergoing abdominal or thoracic trauma surgery remains equivocal. Large, multicentre, methodologically rigorous trials are needed to assess the relative efficacy, safety and cost-effectiveness of cell salvage in different surgical procedures in the emergency context.

High dose rate versus low dose rate intracavity brachytherapy for locally advanced uterine cervix cancer.

BACKGROUND: Carcinoma of the uterine cervix is the second most common cancer and the third leading cause of cancer death among women. Radiotherapy has been used successfully to treat cervical cancer for nearly a century. The combination of external beam radiotherapy (EBRT) and intracavitary brachytherapy (ICBT) has become a standard treatment modality for cervical cancer. Depending on the difference in dose rate on 'Point A' (located 2 cm above the cervical os and 2 cm lateral to the central axis of the uterus), the ICBT is divided into three modalities: low dose rate (LDR), high dose rate (HDR) and medium dose rate (MDR). Despite the practical advantages of HDR, it is necessary to investigate further the efficacy and safety of HDR brachytherapy compared to LDR brachytherapy. Questions arise as to whether HDR or LDR brachytherapy improves results for patients with cervical cancer in terms of local control rates, survival and complications related to treatment. OBJECTIVES: To assess the efficacy and safety of HDR- versus LDR-ICBT for patients with uterine cervical cancer. SEARCH STRATEGY: We searched the Cochrane Gynaecological Cancer Group Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 4), MEDLINE (1966 to November 2009), EMBASE (1974 to November 2009), Chinese Biomedical Literature Database (CBM) (1978 to November 2009) for relevant original, published trials. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs that compared HDR- with LDR-ICBT, combined with EBRT, for patients with locally advanced uterine cervical cancer. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data using standardised forms. Primary outcome measures included overall survival (OS), relapse-free survival (RFS) and pelvic control rate, while secondary outcomes included rates of recurrence and complications. MAIN RESULTS: Four studies involving 1265 patients met the inclusion criteria. In our meta-analysis to compare HDR and LDR, the pooled RRs were 0.95 (95% CI 0.79 to 1.15), 0.93 (95% CI 0.84 to 1.04) and 0.79 (95% CI 0.52 to 1.20) for 3-, 5- and 10-year overall survival rates; and 0.95 (95% CI 0.84 to 1.07) and 1.02 (0.88 to 1.19) for 5- and 10-year disease-specific survival (DSS) rates. The RR for RFS was 1.04 (95% CI 0.71 to 1.52) and 0.96 (95% CI 0.81 to 1.14) at three and five years. For local control rates the RR was 0.95 (95% CI 0.86 to 1.05) and 0.95 (95% CI 0.87 to 1.05) at three and five years; with a RR of 1.09 (95% CI 0.83 to 1.43) for locoregional recurrence, 0.79 (95% CI 0.40 to 1.53) for local and distance recurrence, 2.23 (95% CI 0.78 to 6.34) for para-aortic lymph node metastasis and 0.99 (95% CI 0.72 to 1.35) for distance metastasis. For bladder, rectosigmoid and small bowel complications, the RR was 1.33 (95% CI 0.53 to 3.34), 1.00 (95% CI 0.52 to 1.91) and 3.37 (95% CI 1.06 to 10.72), respectively. These results indicate that there were no significant differences except for increased small bowel complications with HDR (P = 0.04). AUTHORS' CONCLUSIONS: This review showed no significant differences between HDR- and LDR-ICBT when considering OS, DSS, RFS, local control rate, recurrence, metastasis and treatment related complications for women with cervical carcinoma. Due to some potential advantages of HDR-ICBT (rigid immobilization, outpatient treatment, patient convenience, accuracy of source and applicator positioning, individualized treatment) we recommend the use of HDR-ICBT for all clinical stages of cervix cancer.

Robot-assisted laparoscope fundoplication for gastroesophageal reflux disease: a systematic review of randomized controlled trials.

OBJECTIVE: To evaluate the efficacy and safety of robot-assisted fundoplication (RAF) for treating gastroesophageal reflux disease (GERD). METHODS: Randomized controlled trials (RCTs) or quasi-RCTs were searched for in PubMed, EMBASE, the Cochrane Library, SCI, Chinese Biomedical Database, China Academic Journals Full-Text Database, Chinese Scientific Journals Database, China online journals, and related journals. We evaluated the quality of the included studies by using the 5.0.1 Cochrane Handbook standards and analyzed the data using the Cochrane Collaboration's RevMan 5.0. RESULTS: Five studies (n = 181) were included. A meta-analysis showed that besides the time taken to carry out fundoplication (p < 0.00001), both RAF and conventional laparoscopic fundoplication (CLF) were similar in postoperative antisecretory medication (p = 1.0), intraoperative conversion to open surgery (p = 0.94), postoperative dysphagia (p = 1.0), pneumothorax (p = 1.0), total intraoperative complications (p = 0.24), the time of hiatal dissection (p = 0.98), the time of incision to completion of sutures (p = 0.95), total operation time (p = 0.16), hospital stay (p = 0.97), and total cost (p = 0.25). CONCLUSIONS: The current evidence demonstrates that RAF is safe and effective in treating GERD. The weakness of this treatment method is that it prolongs the time necessary to carry out fundoplication. However, RAF should be the future trend for treating GERD.