Correspondence
investigate Hamas’ use of their own people as human shields in this war. Whereas Israel develops missiles to protect their children, Hamas uses their children to protect their missiles. The more civilians who are hit, the greater their illusion of victory. As in operation Cast Lead, Israel established a field hospital on the border with Gaza to help wounded Palestinians. But again, very few patients arrived at this hospital. Hamas leaders prevent access to this medical facility, 3 just as it prevented the evacuation of civilians when leaflets were dropped from Israeli planes to warn about areas that Israel planned to bomb. There is unbearable suffering, civilian casualties, and children being wounded and killed, but there is no moral equivalence in this war. It is outrageous to blame Israel and shield Hamas with implausible excuses. I declare no competing interests.
Yoram Blachar [email protected] Peres Academic Center, Rehovot, Israel 1
2
3
Published Online August 8, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61312-X
580
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; 384: 397–98. UNRWA. UNRWA Condemns placement of rockets, for a second time, in one of its schools. http://www.unrwa.org/newsroom/pressreleases/unrwa-condemns-placement-rocketssecond-time-one-its-schools (accessed Aug 6, 2014). Cohen G. Under Hamas fire, Israel keeps humanitarian aid to Gaza flowing. http://www. haaretz.com/news/diplomacy-defense/israelgaza-conflict-2014/.premium-1.608949 (accessed Aug 6, 2014).
I write to join my fellow health professionals in expressing my support for the people of Gaza, 1 and my outrage at Israel’s attacks on Gaza’s civilians in their homes, hospitals, and UN shelters. As health professionals, our voices matter, since our support for victims in such conflicts tends to be borne out of empathy and compassion for human suffering, rather than political interests. I am Palestinian, and I am equally appalled by civilian
death and suffering on both sides. The reality of the present conflict is that it is the Palestinian civilians who overwhelmingly suffered death, injury, and displacement. As of Aug 6, the UN Office for the Coordination of Humanitarian Affairs estimated that the war had led to the deaths of 1354 Gazan civilians, including 415 children, and two Israeli civilians.2 They are trapped within closed borders with no safe havens, under intensifying bombardment by Israel from land, sea, and air. The absence of safe havens was recently highlighted by the UN Secretary General, “These attacks were outrageous, unacceptable, and unjustifiable”, he said.3 The UN also highlighted Gaza’s “health and humanitarian disaster”, in part caused by Israel’s shelling of hospitals and clinics—leading to deaths and injuries among medical staff “in the line of duty”.4 It is an ethical necessity to be outraged at the avoidable killing of hundreds of Palestinian civilians, and the shelling of the hospitals in which they are treated. A medical journal is a fitting place for health professionals to express such outrage. I am a Palestinian doctor, trained and practising in the UK. I declare no competing interests.
Hind Khalifeh [email protected] Division of Psychiatry, University College London, London W1W 7EJ, UK 1
2
3
4
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; 384: 397–98. UNOCHA.Occupied Palestinian Territory: Gaza Emergency Situation Report (as of 5 Aug 2014, 0800 hrs). http://www.ochaopt.org/ documents/ocha_opt_sitrep_05_08_2014. pdf (accessed Aug 6, 2014). UN Secretary-General Ban Ki-moon. New York, 6 Aug 2014, Secretary-General’s remarks to the General Assembly on the situation in Gaza. http://www.un.org/sg/ statements/index.asp?nid=7913 (accessed Aug 6, 2014). WHO and UNRWA. United Nations warns of “rapidly unfolding” health disaster in Gaza. press release. http://www.ochaopt.org/ documents/Press_Release_UN_warns_of_ imminent_health_disaster_in_Gaza.pdf (accessed Aug 6, 2014).
Adhesion barriers for abdominal surgery and oncology We read with great interest Richard ten Broek and colleagues’ meta-analysis 1 about the use of four different anti-adhesion barriers. Reoperation for adhesive small bowel obstruction was the primary outcome. The authors suggest their results should inform the development of guidelines for the use of barriers to prevent long-term adhesion-related complications for abdominal surgery in general. However, these results are not applicable to surgical oncology. In stage IV colorectal cancer, which is the most frequent cancer affecting the abdomen, advances in chemotherapy during the past decade have enabled us to increase the number of patients treated with repeated abdominal surgery and therefore, exposed to adhesiolysis-related morbidity. As ten Broek and colleagues noted, adhesiolysis is associated with an increase in bowel injury and septic complications.2 Moreover, adhesiolysis time predicts enterotomy.3 Reoperation for adhesive small bowel obstruction is a rare event and needs a long follow-up period if chosen as a primary endpoint in studies. Hence, adhesive small bowel obstruction is probably not the most clinically relevant outcome nor the most suited to clinical trials when assessing the consequences of adhesions in surgical oncology. Instead, a more realistic primary outcome should be chosen. Such an outcome should allow objective evaluation and should be assessable over a short timeframe. In surgical oncology, serious adverse events and adhesiolysis time might be of value. We declare no competing interests.
*Aurélien Dupré, David Pérol, Michel Rivoire [email protected] Léon Bérard Cancer Center, Lyon 69008, France
www.thelancet.com Vol 384 August 16, 2014
investigate Hamas’ use of their own people as human shields in this war. Whereas Israel develops missiles to protect their children, Hamas uses their children to protect their missiles. The more civilians who are hit, the greater their illusion of victory. As in operation Cast Lead, Israel established a field hospital on the border with Gaza to help wounded Palestinians. But again, very few patients arrived at this hospital. Hamas leaders prevent access to this medical facility, 3 just as it prevented the evacuation of civilians when leaflets were dropped from Israeli planes to warn about areas that Israel planned to bomb. There is unbearable suffering, civilian casualties, and children being wounded and killed, but there is no moral equivalence in this war. It is outrageous to blame Israel and shield Hamas with implausible excuses. I declare no competing interests.
Yoram Blachar [email protected] Peres Academic Center, Rehovot, Israel 1
2
3
Published Online August 8, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61312-X
580
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; 384: 397–98. UNRWA. UNRWA Condemns placement of rockets, for a second time, in one of its schools. http://www.unrwa.org/newsroom/pressreleases/unrwa-condemns-placement-rocketssecond-time-one-its-schools (accessed Aug 6, 2014). Cohen G. Under Hamas fire, Israel keeps humanitarian aid to Gaza flowing. http://www. haaretz.com/news/diplomacy-defense/israelgaza-conflict-2014/.premium-1.608949 (accessed Aug 6, 2014).
I write to join my fellow health professionals in expressing my support for the people of Gaza, 1 and my outrage at Israel’s attacks on Gaza’s civilians in their homes, hospitals, and UN shelters. As health professionals, our voices matter, since our support for victims in such conflicts tends to be borne out of empathy and compassion for human suffering, rather than political interests. I am Palestinian, and I am equally appalled by civilian
death and suffering on both sides. The reality of the present conflict is that it is the Palestinian civilians who overwhelmingly suffered death, injury, and displacement. As of Aug 6, the UN Office for the Coordination of Humanitarian Affairs estimated that the war had led to the deaths of 1354 Gazan civilians, including 415 children, and two Israeli civilians.2 They are trapped within closed borders with no safe havens, under intensifying bombardment by Israel from land, sea, and air. The absence of safe havens was recently highlighted by the UN Secretary General, “These attacks were outrageous, unacceptable, and unjustifiable”, he said.3 The UN also highlighted Gaza’s “health and humanitarian disaster”, in part caused by Israel’s shelling of hospitals and clinics—leading to deaths and injuries among medical staff “in the line of duty”.4 It is an ethical necessity to be outraged at the avoidable killing of hundreds of Palestinian civilians, and the shelling of the hospitals in which they are treated. A medical journal is a fitting place for health professionals to express such outrage. I am a Palestinian doctor, trained and practising in the UK. I declare no competing interests.
Hind Khalifeh [email protected] Division of Psychiatry, University College London, London W1W 7EJ, UK 1
2
3
4
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; 384: 397–98. UNOCHA.Occupied Palestinian Territory: Gaza Emergency Situation Report (as of 5 Aug 2014, 0800 hrs). http://www.ochaopt.org/ documents/ocha_opt_sitrep_05_08_2014. pdf (accessed Aug 6, 2014). UN Secretary-General Ban Ki-moon. New York, 6 Aug 2014, Secretary-General’s remarks to the General Assembly on the situation in Gaza. http://www.un.org/sg/ statements/index.asp?nid=7913 (accessed Aug 6, 2014). WHO and UNRWA. United Nations warns of “rapidly unfolding” health disaster in Gaza. press release. http://www.ochaopt.org/ documents/Press_Release_UN_warns_of_ imminent_health_disaster_in_Gaza.pdf (accessed Aug 6, 2014).
Adhesion barriers for abdominal surgery and oncology We read with great interest Richard ten Broek and colleagues’ meta-analysis 1 about the use of four different anti-adhesion barriers. Reoperation for adhesive small bowel obstruction was the primary outcome. The authors suggest their results should inform the development of guidelines for the use of barriers to prevent long-term adhesion-related complications for abdominal surgery in general. However, these results are not applicable to surgical oncology. In stage IV colorectal cancer, which is the most frequent cancer affecting the abdomen, advances in chemotherapy during the past decade have enabled us to increase the number of patients treated with repeated abdominal surgery and therefore, exposed to adhesiolysis-related morbidity. As ten Broek and colleagues noted, adhesiolysis is associated with an increase in bowel injury and septic complications.2 Moreover, adhesiolysis time predicts enterotomy.3 Reoperation for adhesive small bowel obstruction is a rare event and needs a long follow-up period if chosen as a primary endpoint in studies. Hence, adhesive small bowel obstruction is probably not the most clinically relevant outcome nor the most suited to clinical trials when assessing the consequences of adhesions in surgical oncology. Instead, a more realistic primary outcome should be chosen. Such an outcome should allow objective evaluation and should be assessable over a short timeframe. In surgical oncology, serious adverse events and adhesiolysis time might be of value. We declare no competing interests.
*Aurélien Dupré, David Pérol, Michel Rivoire [email protected] Léon Bérard Cancer Center, Lyon 69008, France
www.thelancet.com Vol 384 August 16, 2014
