Efficacy of traction-assisted colorectal endoscopic submucosal dissection using a clip-and-thread technique: A prospective randomized study

BACKGROUND AND AIM

Colorectal endoscopic submucosal dissection (ESD) remains challenging because of technical difficulties, long procedure time, and high risk of adverse events. To facilitate colorectal ESD, we developed traction-assisted colorectal ESD using a clip and thread (TAC-ESD) and conducted a randomized controlled trial to evaluate its efficacy.

METHODS

Patients with superficial colorectal neoplasms (SCN) ≥20 mm were enrolled and randomly assigned to the conventional-ESD group or to the TAC-ESD group. SCN ≤50 mm were treated by two intermediates, and SCN >50 mm were treated by two experts. Primary endpoint was procedure time. Secondary endpoints were TAC-ESD success rate (sustained application of the clip and thread until the end of the procedure), self-completion rate by the intermediates, and adverse events.

RESULTS

Altogether, 42 SCN were analyzed in each ESD group (conventional and TAC). Procedure time (median [range]) for the TAC-ESD group was significantly shorter than that for the conventional-ESD group (40 [11-86] min vs 70 [30-180] min, respectively; P < 0.0001). Success rate of TAC-ESD was 95% (40/42). The intermediates' self-completion rate was significantly higher for the TAC-ESD group than for the conventional-ESD group (100% [39/39] vs 90% [36/40], respectively; P = 0.04). Adverse events included one intraoperative perforation in the conventional-ESD group and one delayed perforation in the TAC-ESD group.

CONCLUSION

Traction-assisted colorectal endoscopic submucosal dissection reduced the procedure time and increased the self-completion rate by the intermediates (UMIN000018612).

Operative treatment of severe scoliosis in osteogenesis imperfecta: results of 20 patients after halo traction and posterior spondylodesis with instrumentation

Correction and stabilisation of the scoliotic spine in osteogenesis imperfecta is difficult. The optimal technique has yet to be determined, since no large series in which a single procedure has been carried out by a single surgeon using a single protocol has yet been described. The charts of 20 patients with osteogenesis imperfecta who had undergone halo gravity traction (HGT) and a posterior spondylodesis with Cotrel-Dubousset (n = 18) or Harrington (n = 2) instrumentation were reviewed. No correction was made at the time of the surgical spondylodesis. The average follow-up was 4.8 years (range 2-10.5 years). The preoperative traction improved the Cobb angle of the scoliosis by 32% (from a mean of 78.5 degrees to a mean of 53.3 degrees) and improved the kyphosis by 24% (from a mean of 56.0 degrees to mean of 42.5 degrees). This correction deteriorated slightly at final follow-up, for both the scoliosis and the kyphosis (mean 57.6 degrees and 44.4 degrees respectively). Few complications were encountered during the HGT period. In 16 cases no complications occurred during the follow-up period. Ambulation and functional ability were upgraded for 7 of 20 patients.

Plectin contributes to mechanical properties of living cells

Plectin is a 500-kDa cross-linking protein that plays important roles in a number of cell functions including migration and wound healing. We set out to characterize the role of plectin in mechanical properties of living cells. Plectin(-/-) cells were less stiff than plectin(+/+) cells, but the slopes of the two power laws in response to loading frequencies (0.002-1,000 Hz) were similar. Plectin(-/-) cells lost the capacity to propagate mechanical stresses to long distances in the cytoplasm; traction forces in plectin(-/-) cells were only half of those in plectin(+/+) cells, suggesting that plectin deficiency compromised prestress generation, which, in turn, resulted in the inhibition of long distance stress propagation. Both plectin(+/+) and plectin(-/-) cells exhibited nonlinear stress-strain relationships. However, plectin(+/+) cells, but not plectin(-/-) cells, further stiffened in response to lysophosphatidic acid (LPA). Dynamic fluorescence resonance energy transfer analysis revealed that RhoA GTPase proteins were activated in plectin(+/+) cells but not in plectin(-/-) cells after treatment with LPA. Expression in plectin(-/-) cells of constitutively active RhoA (RhoA-V14) but not a dominant negative mutant of RhoA (RhoA-N19) or an empty vector restored the long distance force propagation behavior, suggesting that plectin is important in normal functions of RhoA. Our findings underscore the importance of plectin for mechanical properties, stress propagation, and prestress of living cells, thereby influencing their biological functions.

Cellular Biomechanics in Drug Screening and Evaluation: Mechanopharmacology

The study of mechanobiology is now widespread. The impact of cell and tissue mechanics on cellular responses is well appreciated. However, knowledge of the impact of cell and tissue mechanics on pharmacological responsiveness, and its application to drug screening and mechanistic investigations, have been very limited in scope. We emphasize the need for a heightened awareness of the important bidirectional influence of drugs and biomechanics in all living systems. We propose that the term 'mechanopharmacology' be applied to approaches that employ in vitro systems, biomechanically appropriate to the relevant (patho)physiology, to identify new drugs and drug targets. This article describes the models and techniques that are being developed to transform drug screening and evaluation, ranging from a 2D environment to the dynamic 3D environment of the target expressed in the disease of interest.

Developmental and Early Life Origins of Cardiometabolic Risk Factors: Novel Findings and Implications

The intent of this review is to critically consider the data that support the concept of programming and its implications. Birth weight and growth trajectories during childhood are associated with cardiometabolic disease in adult life. Both extremes, low and high birth weight coupled with postnatal growth increase the early presence of cardiometabolic risk factors and vascular imprinting, crucial elements of this framework. Data coming from epigenetics, proteomics, metabolomics, and microbiota added relevant information and contribute to better understanding of mechanisms as well as development of biomarkers helping to move forward to take actions. Research has reached a stage in which sufficiently robust data calls for new initiatives focused on early life. Prevention starting early in life is likely to have a very large impact on reducing disease incidence and its associated effects at the personal, economic, and social levels.

Lumbar Traction for Managing Low Back Pain: A Survey of Physical Therapists in the United States

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

To examine how many physical therapists use traction, the patients for whom traction is used, the preferred delivery modes/parameters of traction, the supplemental interventions used with traction, and whether professional characteristics influence traction usage.

BACKGROUND

Several systematic reviews and clinical guidelines have questioned the effectiveness of traction for managing low back pain, yet some patients may benefit from lumbar traction. While traction usage among physical therapists in other countries has been described, usage among physical therapists in the United States has not been examined.

METHODS

We surveyed a random sample of 4000 Orthopaedic Section members of the American Physical Therapy Association. Associations among respondents' professional characteristics and survey responses were explored with chi-square analyses (α = .05).

RESULTS

The response rate was 25.5% (n = 1001), and 76.6% (n = 767) of respondents reported using traction. Most (58.4%) of the respondents used traction for patients with signs of nerve root compression, though many (31.4%) did not. Common delivery modes included manual methods (68.3%) and mechanical tables (44.9%), most often supplemental to other interventions (eg, stabilization exercises, postural education). Levels of professional preparation (doctoral/masters level versus bachelors/certificate level) were associated with many variables, as was attainment of an orthopaedic specialist certification.

CONCLUSION

Most of the orthopaedic physical therapists in the United States who responded to our survey reported that they used lumbar traction, though not necessarily consistent with proposed criteria that identify patients most likely to benefit from traction. They used various traction delivery modes/parameters and used traction within comprehensive plans of care incorporating multiple interventions. Professional characteristics (education levels and clinical specialist credentialing) were associated with traction usage.

Improving visualization of the central compartment of the hip with direct MR arthrography under axial leg traction: a feasibility study

RATIONALE AND OBJECTIVES

To evaluate the feasibility of a modified approach for direct magnetic resonance (MR) arthrography of the hip under leg traction in achieving a sufficient femoroacetabular interface and improving the visualization of the ligamentum teres.

MATERIALS AND METHODS

Forty-six MR arthrograms of 44 patients who underwent MR arthrography with and without leg traction were included into the study. Traction approach included injection of 18-27 mL of fluid (local anesthetic, contrast agent), application of weight-adapted traction load (15-23 kg), and the use of a supporting plate. Patients were instructed to report on pain and complications with an integer pain scale. Joint distraction was measured on coronal images obtained with and without traction, and two radiologists independently evaluated whether femoroacetabular cartilage layers and the ligamentum teres could be seen as distinct entities. McNemar test was used and interobserver agreement was assessed.

RESULTS

No patient asked for termination of the examination. There were no cases of neuropraxia. Mean difference in distraction was 3.7 mm/3.6 mm (reader 1/reader 2). Cartilage layers could be seen as distinct entities in 43/43 (93.5%/93.5%) and 6/8 (13%/17.4%) of the joints with/without traction (P < .001/P < .001), respectively. The ligamentum teres could be differentiated in 33/30 (71.7%/65.2%) cases with traction, in 33/30 (71.7%/65.2%) cases without traction (P < .999/P < .999), and in 40/37 (87%/80.4%) cases with both the techniques combined.

CONCLUSIONS

Traction MR arthrography is safe and technically feasible. It enabled the differentiation between femoroacetabular cartilage layers in most cases. Visualization of the ligamentum teres was optimal by combining imaging with both modalities.

Effects of Hip Arthroscopy Without a Perineal Post on Venous Blood Flow, Muscle Damage, Peripheral Nerve Conduction, and Perineal Injury: A Prospective Study

BACKGROUND

Prior reports of hip arthroscopy using a perineal post have established the risks of groin soft tissue injury, sexual dysfunction, and altered lower extremity neurovascular function. These parameters have not been investigated for hip arthroscopy without the use of a perineal post.

PURPOSE

To evaluate the effects of postless hip arthroscopy on lower extremity venous blood flow, nerve conduction, muscle tissue damage, and perineal injury.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients between the ages of 18 and 50 years undergoing an elective unilateral or simultaneous bilateral hip arthroscopy were enrolled. Creatine phosphokinase (CPK)-MM levels and D-dimer levels were obtained preoperatively, immediately postoperatively, and 7 to 12 days postoperatively. Bilateral Doppler ultrasonography of the common femoral vein (CFV) and popliteal vein were conducted intraoperatively. Somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TcMEPs) were measured intraoperatively for the lower limbs. Perineal injury was assessed at 7 to 12 days postoperatively.

RESULTS

35 patients underwent a total of 40 hip arthroscopies. No significant differences were found in venous blood flow between the operative and nonoperative legs for either the CFV or popliteal vein. SSEP monitoring of the peroneal nerve showed no significant reduction when traction was applied to the operative leg, 90.8%, compared with final measurement just before it was removed, 72.4% (P = .09). For TcMEPs measured in the muscles outside of the traction boots, no significant changes were seen in the percentage of cases with abnormal measurements throughout the procedure. CPK-MM levels preoperatively, immediately postoperatively, and 7 to 12 days after surgery were on average 112, 190, and 102 IU/L, respectively (normal, <156 IU/L). No significant relationship was found between abnormal venous flow and altered D-dimer levels. No clinical evidence of nerve or vascular injury was encountered, and no groin soft tissue complications were observed during the study period.

CONCLUSION

Postless hip arthroscopy is safe, without a notable reduction of venous blood flow or alteration of nerve function in the operative leg. Muscle tissue damage is subclinical, transient, and reduced compared with distraction with a post. No cases of perineal injury were observed during the study period.

Traction table versus standard table total hip arthroplasty through the direct anterior approach: a systematic review

BACKGROUND

The direct anterior approach (DAA) for total hip arthroplasty (THA) was originally performed with a supine patient on a specialised traction table, but the approach can also be performed on a standard operating table. Despite cost and safety implications, there are few studies directly comparing these techniques and table choice remains largely surgeon preference. The purpose of this review was to compare the clinical outcomes and complication profiles of traction and standard table DAA for primary THA.

METHODS

The authors searched databases for relevant studies, screening in duplicate. Study quality was assessed using MINORS criteria or Cochrane Risk of Bias Tool. Data pertaining to patient demographics, clinical outcomes, and complications were abstracted.

RESULTS

Of 3085 initial titles, 44 studies containing a total 26,353 patients were included and analysed. Mean operative time was 70.9 ± 21.2 minutes for standard table (n = 4402) and 100.1 ± 32.6 minutes for traction table (n = 3518). Mean estimated blood loss was 382.3 ± 246.4 mL for standard (n = 2992) and 531.7 ± 364.3 mL for traction table (n = 2675). Intra-operative fracture rate was 1.3% for standard table (n = 3940) and 1.7% for traction table (n = 8386). Complication rates including revisions, dislocations and peri-prosthetic fractures were qualitatively similar between traction and standard table studies.

CONCLUSION

Standard table and traction table DAA have similar outcomes and complications. Both techniques offer the short-term advantages of DAA when compared to other THA approaches. However, the standard table technique may offer perioperative advantages including decreased blood loss, shorter operative time, and fewer intraoperative fractures. In the context of rising global healthcare costs and lack of access to specialised orthopaedic traction tables, this review at minimum confirms the short-term safety of standard table DAA THA and prompts the need for future studies to directly compare these techniques.

Regression of lumbar disc herniation by physiotherapy. Does non-surgical spinal decompression therapy make a difference? Double-blind randomized controlled trial

BACKGROUND AND OBJECTIVES

The aim of the study determining whether or not Non-invasive Spinal Decompression Therapy (NSDT) was effective in resorption of herniation, increasing disc height in patients with lumbar disc herniation (LHNP).

METHODS

A total of twenty patients diagnosed as LHNP and suffering from pain at least 8 weeks were enrolled to the study. Patients were allocated in study (SG) and control groups (CG) randomly. Both groups received combination of electrotherapy, deep friction massage and stabilization exercise for fifteen session. SG received additionally NSDT different from CG. Numeric Anolog Scale, Straight leg raise test, Oswestry Disability Index (ODI) were applied at baseline and after treatment. Disc height and herniation thickness were measured on Magnetic Resonance Imagination which performed at baseline and three months after therapy.

RESULTS

Both treatments had positive effect for improving pain, functional restoration and reduction in thickness of herniation. Although reduction of herniation size was higher in SG than CG, no significant differences were found between groups and any superiority to each other (p> 0.05).

CONCLUSIONS

This study showed that patients with LHNP received physiotherapy had improvement based on clinical and radiologic evidence. NSDT can be used as assistive agent for other physiotherapy methods in treatment of lumbar disc herniation.

Endoscopic instruments and techniques in endoscopic submucosal dissection for early gastric cancer

Introduction: Endoscopic submucosal dissection (ESD) is a less invasive local treatment for early gastric cancer (EGC).Areas covered: Japanese guidelines have recently expanded the endoscopic treatment indications for EGC. ESD is sometimes performed for lesions with a relative indication that has not previously been considered for ESD. ESD procedures are technically difficult, especially for larger and more invasive lesions. Complete resection and accurate histological assessment of EGC lesions are essential to evaluate endoscopic curability. Various endoscopic instruments, including three types of endoscopic knives and specific hemostatic forceps, have been developed, and endoscopic techniques, including the traction method, have been modified to simplify the procedure.Expert opinion: An insulated-tip knife with large tissue contact allows us to perform faster incisions, while a needle-type knife with minimal tissue contact allows us to perform precise incisions. Furthermore, a scissor-type knife with grasping tissues allows us to perform more secure incision. The traction method enables the operator to proceed with submucosal dissection procedures. In cases with small lesions, snaring can be used, as well as knife dissection. Understanding the features of each endoscopic instrument and technique is essential because appropriate selection and usage contribute to successful and safe ESD procedures.

Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics in cervical spondylotic radiculopathy subjects?

OBJECTIVE

To test the hypothesis that improvement of cervical lordosis in cervical spondylotic radiculopathy (CSR) will improve cervical spine flexion and extension end range of motion kinematics in a population suffering from CSR.

METHODS

Thirty chronic lower CSR patients with cervical lordosis < 25° were included. IRB approval and informed consent were obtained. Patients were assigned randomly into two equal groups, study (SG) and control (CG). Both groups received stretching exercises and infrared; the SG received 3-point bending cervical extension traction. Treatments were applied 3 × per week for 10 weeks, care was terminated and subjects were evaluated at 3 intervals: baseline, 30 visits, and 3-month follow-up. Radiographic neutral lateral cervical absolute rotation angle (ARA C2-C7) and cervical segmental (C2-C7 segments) rotational and translational flexion-extension kinematics analysis were measured for all patients at the three intervals. The outcome were analyzed using repeated measures one-way ANOVA. Tukey's post-hoc multiple comparisons was implemented when necessary. Pearson correlation between ARA and segmental translational and rotational displacements was determined.

RESULTS

Both groups demonstrated statistically significant increases in segmental motion at the 10-week follow up; but only the SG group showed a statistically significant increase in cervical lordosis (p < 0.0001). At 3-month follow up, only the SG improvements in segmental rotation and translation were maintained.

CONCLUSION

Improved lordosis in the study group was associated with significant improvement in the translational and rotational motions of the lower cervical spine. This finding provides objective evidence that cervical flexion/extension is partially dependent on the posture and sagittal curve orientation. These findings are in agreement with several other reports in the literature; whereas ours is the first post treatment analysis identifying this relationship.

Ulnar nerve strain at the elbow in patients with cubital tunnel syndrome: effect of simple decompression

Simple decompression of the ulnar nerve at the elbow has not been shown to reduce nerve strain in cadavers. In this study, ulnar nerve strain at the elbow was measured intraoperatively in 11 patients with cubital tunnel syndrome, before and after simple decompression. Statistical analysis was performed using a paired Student's t-test. Mean ulnar nerve strain before and after simple decompression was 30.5% (range 9% to 69%) and 5.5% (range -2% to 11%), respectively; this difference was statistically significant (p < 0.01) with a statistical power of 96%. Simple decompression reduced ulnar nerve strain in all patients by an average of 24.5%. Our results suggest that the pathophysiology of cubital tunnel syndrome may be multifactorial, being neither a simple compression neuropathy nor a simple traction neuropathy, and simple decompression may be a favourable surgical procedure for cubital tunnel syndrome in terms of decompression and reduction of strain in the ulnar nerve.

Effects of segmental traction therapy on lumbar disc herniation in patients with acute low back pain measured by magnetic resonance imaging: A single arm clinical trial

BACKGROUND

Low Back Pain (LBP) is considered as one of the most frequent disorders, which about 80% of adults experience in their lives. Lumbar disc herniation (LDH) is a cause for acute LBP. Among conservative treatments, traction is frequently used by clinicians to manage LBP resulting from LDH. However, there is still a lack of consensus about its efficacy.

OBJECTIVE

The purpose of this study was to evaluate the effects of segmental traction therapy on lumbar discs herniation, pain, lumbar range of motion (ROM), and back extensor muscles endurance in patients with acute LBP induced by LDH.

METHODS

Fifteen patients with acute LBP diagnosed by LDH participated in the present study. Participants undertook 15 sessions of segmental traction therapy along with conventional physiotherapy, 5 times a week for 3 weeks. Lumbar herniated mass size was measured before and after the treatment protocol using magnetic resonance imaging. Furthermore, pain, lumbar ROM and back muscle endurance were evaluated before and after the procedure using clinical outcome measures.

RESULTS

Following the treatment protocol, herniated mass size and patients' pain were reduced significantly. In addition, lumbar flexion ROM showed a significant improvement. However, no significant change was observed for back extensor muscle endurance after the treatment procedure.

CONCLUSION

The result of the present study showed segmental traction therapy might play an important role in the treatment of acute LBP stimulated by LDH.

The effects of neural mobilization on cervical radiculopathy patients' pain, disability, ROM, and deep flexor endurance

BACKGROUND

Cervical radiculopathy (CR) is a disease of the cervical spine and a space-occupying lesion that occurs because of pathological problems with cervical nerve roots. Nerve root injury to produce functional disability.

OBJECTIVE

The purpose of this study was to examine the effects of neural mobilization with manual cervical traction (NMCT) compared with manual cervical traction (MCT) on pain, functional disability, muscle endurance, and range of motion (ROM) in individuals with CR patients.

METHODS

A blinded randomized clinical trial was conducted. Thirty CR patients were divided into two groups - those who received NMCT and those who received MCT. The intervention was applied three times per week for eight weeks. It was measured in order to determine the pain and functional disability in patients with CR. The numeric pain rating scale (NPRS), neck disability index (NDI), ROM, and deep flexor endurance of patients were measured prior to the experiment, four weeks, and eight weeks after the experiment to compare the time points. A repeated-measures analysis of variance was used to compare differences within each group prior to the experiment. And Bonferroni test was performed to examine the significance of each time point.

RESULTS

There were significant differences within each group prior to the intervention, four weeks after the intervention, and eight weeks after the intervention in NPRS, NDI, ROM, and deep flexor endurance (P< 0.05). NPRS and NDI more decreased, and, ROM and deep flexor endurance increased in the NMCT group than the MCT group (P< 0.05).

CONCLUSIONS

These results suggest that the NMCT can pain relief, recovery from neck disability, ROM, and deep flexor endurance for patients with CR.

A non-randomized clinical control trial of Harrison mirror image methods for correcting trunk list (lateral translations of the thoracic cage) in patients with chronic low back pain

Spinal trunk list is a common occurrence in clinical practice, but few conservative methods of spinal rehabilitation have been reported. This study is a non-randomized clinical control trial of 63 consecutive retrospective subjects undergoing spinal rehabilitation and 23 prospective volunteer controls. All subjects presented with lateral thoracic-cage-translation posture (trunk list) and chronic low back pain. Initial and follow-up numerical pain rating scales (NRS) and AP lumbar radiographs were obtained after a mean of 11.5 weeks of care (average of 36 visits) for the treatment group and after a mean of 37.5 weeks for the control group. The radiographs were digitized and analyzed for a horizontal displacement of T12 from the second sacral tubercle, verticality of the lumbar spine at the sacral base, and any dextro/levo angle at mid-lumbar spine. Treatment subjects received the Harrison mirror image postural correction methods, which included an opposite trunk-list exercise and a new method of opposite trunk-list traction. Control subjects did not receive spinal rehabilitation therapy, but rather self-managed their back pain. For the treatment group, there were statistically significant improvements (approximately 50%) in all radiographic measurements and a decrease in pain intensity (NRS: 3.0 to 0.8). For the control group, no significant radiographic and NRS differences were found, except in trunk-list displacement of T12 to S1, worsened by 2.4 mm. Mirror image (opposite posture) postural corrective exercises and a new method of trunk-list traction resulted in 50% reduction in trunk list and were associated with nearly resolved pain intensity in this patient population. The findings warrant further study in the conservative treatment of chronic low back pain and spinal disorders.

The Posterior Capsular Ligamentous Complex Contributes to Hip Joint Stability in Distraction

BACKGROUND

Laxity of soft tissues after total hip arthroplasty is considered to be a cause of accelerated wear of bearing surfaces and dislocation. The purpose of this study is to assess the contribution of the anterior and posterior capsular ligamentous complexes and the short external rotators, except the quadratus femoris, on the stability of the hip against axial traction.

METHODS

The study subjects comprised 7 fresh cadavers with 12 normal hip joints. In 6 hips, soft tissues surrounding the hip joint were resected in the following order to simulate the anterior approach: anterior capsule, posterior capsule, piriformis, conjoined tendon, and external obturator. In the remaining 6 hips, soft tissues were resected in the following order to simulate the posterior approach: piriformis, conjoined tendon, external obturator, posterior capsule, and anterior capsule. Soft tissue tension was measured by applying traction amounting to 250 N with joints in the neutral position.

RESULTS

The separation distance between the femoral head and acetabulum during axial leg traction significantly increased from 4.0 to 14.5 mm on average after circumferential resection of the capsule via the anterior approach. Subsequent resection of the short external rotators increased the separation distance up to 19.0 mm, but the differences did not reach statistical significance. Resection of the short external rotators via the posterior approach did not significantly increase the separation distance; it significantly increased from 6.0 to 11.4 mm after the resection of the anterior capsule and further to 20.5 mm after the resection of the posterior capsule.

CONCLUSION

The posterior capsule, in addition to the anterior capsule, significantly contributes to hip joint stability in distraction regardless of whether the short external rotators, except the quadratus femoris, were preserved or resected.

Pressure and traction on a model fetal head and neck associated with the use of forceps, Kiwi™ ventouse and the BD Odon Device™ in operative vaginal birth: a simulation study

Objective

To determine the pressure and traction forces exerted on a model fetal head by the BD Odon Device, forceps and Kiwi ventouse during simulated births.

Design

Simulation study.

Setting

Simulated operative vaginal birth.

Population or Sample

84 simulated operative vaginal births.

Methods

A bespoke fetal mannequin with pressure sensors around the head and strain gauge across the neck was used to investigate pressure applied over the head, and traction across the neck during 84 simulated births using the BD Odon Device, non-rotational forceps and Kiwi ventouse.

Main Outcome Measures

Peak pressure on the fetal face and lateral aspects of the head during correct use of the BD Odon Device and forceps. Peak pressure on orbits and neck during misplacement of the BD Odon Device and forceps. Peak traction force generated until instrument failure using the BD Odon Device, forceps and Kiwi ventouse.

Results

When correctly sited and using 80kPa inflation pressure on the cuff, the BD Odon Device generated a lower peak pressure on the fetal head than forceps (83kPa vs 146kPa). When instruments were purposefully misplaced over the orbits the BD Odon Device generated a lower peak pressure on the orbits than forceps (70kPa vs 123kPa). When purposefully misplaced over the neck the BD Odon Device, compared to forceps, generated a greater peak pressure on the anterio-lateral aspect of the neck (56kPa vs 17kPa) and a lower peak pressure on the posterior aspect of the neck (76kPa vs 93kPa) than forceps. In cases of true cephalic disproportion the BD Odon Device ‘popped-off’ at a lower traction force than forceps (208N vs 270N).

Conclusions

In simulated assisted vaginal birth with correctly placed instruments the peak pressure exerted on the fetal head by a BD Odon Device is lower than pressure exerted by non-rotational forceps. In cases in which delivery of the fetal head is not possible due to cephalo-pelvic disproportion lower traction forces could be applied using the BD Odon Device than with forceps before the procedure was abandoned due to device failure.

Randomized controlled trial comparing conventional and traction endoscopic submucosal dissection for early colon tumor (CONNECT-C trial)

OBJECTIVES

Endoscopic submucosal dissection (ESD) is a widely used treatment for early gastrointestinal cancer. However, colon ESD remains challenging. Previous studies on colon ESD using the traction method used a small sample, single-center design, providing insufficient evidence of this procedure's efficacy. We thus aimed to investigate the efficacy and safety of the traction method in colon ESD in this multicenter randomized trial.

METHODS

We conducted a prospective, multicenter, randomized, two-arm controlled trial at 10 facilities in Japan. A 1:1 allocation was conducted for the conventional ESD (C-ESD) and traction ESD (T-ESD) groups. The primary end-point was ESD procedure time.

RESULTS

We included 128 C-ESD and 123 T-ESD cases from April 2020 to August 2021. The median procedure times for C-ESD and T-ESD were 61 (40-100) and 53 (40-76) min (P = 0.18), respectively, and no significant differences were observed between the groups. Subgroup analysis showed that the median procedure times for patients with a lesion diameter of ≥30 mm in the C-ESD and T-ESD groups were 89 (57-80) and 69 (50-104) min (P = 0.05), respectively, and for nonexpert operators were 81 (62-120) and 64 (52-109) min (P = 0.07), respectively.

CONCLUSIONS

The traction method did not contribute to a significantly shortened ESD procedure time. However, this method may be useful when the tumor diameter is large or if the procedure is conducted by nonexpert endoscopists.

Two-Stage Thoracoscopic Repair of Long-Gap Esophageal Atresia Using Internal Traction Is Safe and Feasible

BACKGROUND

The treatment of long-gap esophageal atresia remains an issue for pediatric surgeons. Many techniques for treating long-gap esophageal atresia have been proposed, but the optimal method has not been established. The thoracoscopic esophageal elongation technique has recently been developed. We previously reported a case in which two-stage thoracoscopic repair was performed using internal esophageal traction without esophageal tearing, and we retrospectively reviewed the outcomes of this procedure in this study.

METHODS

Five patients underwent thoracoscopic treatment involving internal esophageal traction for esophageal atresia involving a long gap or vascular ring over a 5-year period.

RESULTS

Between November 2010 and November 2015, 5 patients were treated with thoracoscopic traction. All of these patients successfully underwent thoracoscopic-delayed primary anastomosis. Conversion to open thoracotomy was not required in any case. The postoperative complications experienced by the patients included minor anastomotic leakage in 2 cases, anastomotic stenosis in 1 case, gastroesophageal reflux (GER) in 4 cases, and a hiatal hernia in 1 case. None of the patients died.

CONCLUSIONS

Two-stage thoracoscopic repair for esophageal atresia involving a long gap or vascular ring is a safe and feasible procedure; however, we must develop methods for treating minor anastomotic complications and GER due to esophageal traction in future.

Inner thigh taping vs traction for cervical ripening with a Foley catheter: a randomized controlled trial

OBJECTIVE

To assess the effectiveness of inner thigh "Taping" compared with "Traction" using a weighted bag when an intracervical Foley catheter is used for cervical ripening.

STUDY DESIGN

We performed a randomized controlled trial at a tertiary hospital on women with a singleton pregnancy in cephalic presentation admitted for labor induction with a Bishop score ≤6. A 30 mL intracervical Foley catheter was placed for ripening. Women were randomly allocated to inner thigh Taping or to Traction with a 500 mL weighted bag of fluid. The primary outcome was time to delivery. Secondary outcomes were time to expulsion of the catheter, maternal discomfort (visual analog scale), mode of delivery, and maternal morbidities.

RESULTS

We randomized 197 women. After exclusions (4 ineligible, 2 withdrawn by provider), we analyzed 191 (96 Taping, 95 Traction) women in their assigned groups. Groups were similar regarding maternal race, age, parity, gestational age, and induction indication. Time to delivery was not significantly different (mean ± standard deviation: 19.8 ± 8.5 vs 18.8 ± 8.0 hours; P = .39). Time to catheter expulsion was shorter in the Traction Group (median, 2.6; range, 0.2-10.8 vs median, 1.5; range, 0.1-6.3 hours; P < .001). Change in Bishop and pain scores, cesarean delivery rates, clinical amnionitis, and other maternal morbidities were similar between groups. Subset analyses of those with vaginal delivery and among nulliparas, and multiparas revealed similar results.

CONCLUSION

Traction on the intracervical Foley catheter during cervical ripening shortens the time to spontaneous catheter expulsion without affecting the time to delivery.

Early Clinical Outcome of Staged Laparoscopic Traction Orchidopexy for Abdominal Testes

AIMS OF THE STUDY

To assess the short-term clinical outcome of the novel Shehata technique of laparoscopic traction-lengthening for abdominal testes in a single center over a 12-month period (January-December 2014). An ethics approval of the study and appropriate consents were obtained for all patients before inclusion in our study.

MATERIALS AND METHODS

A total of 47 consecutive boys presented with impalpable testes in the ipsilateral hemiscrota, 3 of them were bilateral summing up to a total of 50 U of impalpable testes to a single center over 12 months (January-December 2014). Those boys underwent a preoperative ultrasound (US) Doppler scan for the ipsilateral and contralateral testes. They then proceeded to a first-stage laparoscopic exploration for the testes in which the cranial testicular artery and the caudal vas deferens were traced to their meeting point to locate the abdominal testes that were either found (peeping at the internal inguinal ring [IIR] or more cranially) or otherwise vanishing (intraabdominally blind-ending vas and vessels or extra-abdominally passing through the IIR). All 50 testes failed to stay at the contralateral IIR when brought there mandating a preliminary lengthening of the testicular vessels by lateral dissection, traction, and fixation to a point 1-2 cm superolateral to the contralateral anterior superior iliac spine (ASIS), essentially a mobile traction point. After 12 weeks, all underwent a second-stage laparoscopic-assisted ipsilateral subdartos orchidopexy for the testes under traction. Occasional slippage of the testis under traction mandated an otherwise second-stage retraction and a third-stage orchidopexy. All underwent US Doppler scan 3 and 6 months after orchidopexy.

RESULTS

The 47 cryptorchid boys presented at a mean age of 3 years 2 months (range: 6 months-8 years). Out of the 50 impalpable testes, 9 were nonvisualized on preoperative US Doppler scan and 16 were vanishing on laparoscopic exploration: 5 abdominally (in utero vascular accident) and 11 scrotally (perinatal torsion). The remaining 34 testes were fixed loosely near the contralateral ASIS in the first-stage laparoscopic exploration. Out of which, 3 had slipped traction at the second stage. The 12-week traction interval went uneventfully and a predefinitive US Doppler scan confirmed viability of all testes under traction. All 34 elongated testes were mobilized and fixed in the ipsilateral hemiscrota inside a created subdartos pouch (of de Netto). All 34 fixed testes were confirmed viable on US Doppler scan 1, 3, and 6 months after orchidopexy.

CONCLUSION

The novel Shehata technique of staged laparoscopic traction-lengthening for abdominal testes is safe, easy, and convenient as evidenced by our limited early experience. Neither internal herniation complicated the traction period nor testicular atrophy (by undue tension) complicated the traction or follow-up periods. We believe it is a good alternative to the Fowler-Stephens staged orchidopexy that entails risky division of the testicular vessels.

Shi-style cervical manipulations for cervical radiculopathy: A multicenter randomized-controlled clinical trial

BACKGROUND

There is a lack of high-quality evidence supporting the use of manipulation therapy for patients with cervical radiculopathy (CR). This study aimed to evaluate the effectiveness of Shi-style cervical manipulations (SCMs) versus mechanical cervical traction (MCT) for CR.

METHODS

This was a randomized, open-label, controlled trial carried out at 5 hospitals in patients with CR for at least 2 weeks and neck pain. The patients received 6 treatments of SCM (n = 179) or MCT (n = 180) over 2 weeks. The primary outcome was participant-rated disability (neck disability index), measured 2 weeks after randomization. The secondary outcomes were participant-rated pain (visual analog scale) and health-related quality of life (36-Item Short Form Health Survey [SF-36]). Assessments were performed before, during, and after (2, 4, 12, and 24 weeks) intervention.

RESULTS

After 2 weeks of treatment, the SCM group showed a greater improvement in participant-rated disability compared with the control group (P = .018). The SCM group reported less disability compared with the control group (P < .001) during the 26-week follow-up. The difference was particularly important at 6 months (mean -28.91 ± 16.43, P < .001). Significant improvements in SF-36 were noted in both groups after 2 weeks of treatment, but there were no differences between the 2 groups.

CONCLUSION

SCM could be a better option than MCT for the treatment of CR-related pain and disability.

Traction force for peroperative hip dislocation in hip arthroscopy

OBJECTIVES

Traction force widens the joint space during hip arthroscopy. It is unclear how much the traction force varies and if it is related to the joint space widening. Main goal of our study was to measure the amount of force needed to widen the hip joint. Second goal was to study the relation between this force and the amount of joint space widening.

METHODS

Traction force was measured in 27 patients (of whom 24 female, mean age 41) during arthroscopy. Measurements were performed before the procedure, after vacuum seal release and after capsulotomy. Joint space widening was measured with fluoroscopy and was calibrated. Friedman and Wilcoxon tests were used to measure differences in traction. The Spearman's rho correlation coefficient was used to identify a correlation in traction force and joint space widening. Regression analyses were used to identify relations between age, body mass index (BMI), hip degeneration and traction force.

RESULTS

The median traction force before arthroscopy was 714 N, lowered to 520 N after vacuum seal release and to 473 N after capsulotomy (p < 0.001). Median joint space widening was 8.8 mm. Spearmans' rho correlation between traction force and joint space widening was ‒0.13.

DISCUSSION

Median traction force of 714 N resulted in 8.8 mm of joint space widening. This traction force was significantly lowered by 200 N after release of the vacuum seal of the hip and 250 N after additional capsulotomy without loss of joint space narrowing. No significant relation was identified for age, BMI or progression of the Kellgren-Lawrence classification for hip degeneration and traction force. Netherlands Trial Registry number 8610.