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I Introduction. In generalizing the experience of providing medical care to the wounded in armed conflicts, a special place belongs to the analysis of the magnitude and structure of casualties, which depend on the conditions, forms and methods of hostilities. The purpose. Conduct a clinical and epidemiological analysis of the proportion of gunshot and mine injuries in the structure of combat surgical trauma during the Anti-terrorist operation / Joint Forces operation. Materials and methods. The total number of wounded as a result of the armed conflict in eastern Ukraine in the period from 2014 to 2019 was more than 41 thousand people, from them killed among the civilian population – 3350 people and 4100 – servicemen. Results. It was proved that the wounded with non-severe combat surgical trauma are 36.5%, severe – 48.9%, extremely severe – 14.6%. Shrapnel wounds were received by 35.3%, bullet wounds – 48.3%, mine injuries – 16.6%. Isolated combat surgical trauma was found in 16.8%, multiple – in 34.3%, combined – in 48.9% of the wounded. Impenetrable combat surgical trauma was diagnosed in 63.7% of the wounded, penetrating into the pleural cavity – in 17.2%, in the abdominal cavity – in 16.0%, in the pelvic cavity – in 3.1%. Conclusions. In the structure of sanitary losses of the surgical profile during the ATO / OOS, the wounded with injuries of the extremities are 56.7%, with injuries of the chest – 10.1%, abdomen – 5.1%, pelvis – 3.0%.

The analysis of injuries, life-threatening consequences and outcomes of treatment of wounded with penetrating chest wounds and the results of approbation of a prototype (medical) disposable set UD-02v for the elimination of strained and open pneumothorax, hemothorax, pleural drainage and collection of spilled blood with the possibility of subsequent reinfusion at the pre-hospital stage is presented. The prototype of the UD-02v set was created as part of the implementation of the state defense order in 2018. Its creation is due to the fact that despite the improvement of medical care at the stages of medical evacuation and the widespread use of individual armor protection, chest injuries currently remain a frequent type of combat surgical injury, accounting for 6 to 12% of all injuries. The main cause of death of injured and injured with chest injuries remains blood loss caused by continuing intrapleural bleeding and concomitant damage to other anatomical areas. Stressful pneumothorax, together with intrapleural bleeding, account for 93% of preventable causes of fatal chest injuries at the pre-hospital stage. Untimely elimination of the consequences of severe breast injuries should be considered as a negative factor affecting the outcome of treatment, and significant improvement in treatment results should be expected only in the case of early elimination of the most severe consequences of breast injuries. The developed set of UD-02v exceeds foreign medical devices in its medical and technical characteristics, and is the most promising for acceptance for the supply of the Armed forces of the Russian Federation as part of the samples of complete and service equipment.

Objective To compare the outcomes of patients who underwent early repair (≤7 days) of iatrogenic ureteral injury with ureteroneocystostomy and compare them to those repaired in a delayed fashion (>7 days). Methods A retrospective review of billing data between 2012 and 2018 identified patients who underwent ureteroneocystostomy for a benign ureteral disease. Inclusion criteria included all ureteral injuries related to a laparoscopic, robotic, or open surgical injury. Patients with ureteral injury related to radiation, stones, or reconstructive surgery were excluded. Patients undergoing reconstruction during the initial injury or within ≤7 days were designated as having undergone early repair, while the remaining were considered delayed repair. Demographics, as well as inpatient and postdischarge data were acquired, and statistical analysis was performed comparing the 2 groups. Results Sixty-seven patients met inclusion criteria. Early repair was performed on 12 patients, while 55 underwent delayed repair. No significant difference in age, gender, Charlson Comorbidity Score, laterality, stricture location, or history of pelvic/abdominal radiation was noted. Inpatient complications were significantly higher in the immediate group (58 vs 18%, P =.004). Thirty- and 90-day complications were similar. Two patients in the delayed group and none in the immediate group demonstrated stricture recurrence (P =.710). A higher rate of Boari flap ureteral reconstruction was performed in the delayed cohort (P =.001). Conclusion In this cohort, there was no detectable difference in outcomes when comparing early and delayed ureteroneocystostomy for iatrogenic ureteral injuries.

Objective: The aim is to evaluate the location and proximity of second and third molars roots to the inferior alveolar canal (IAC) and demographic factors associated with these proximities. Materials and Methods: Cone beam computed tomography scans were evaluated for 292 roots of 146 teeth from 40 patients. A radiologist read, measured, and evaluated the vertical and horizontal positions of the roots of the second and third molars in relation to the IAC. Results: No significant differences were found between the third molar roots and neighboring second molar roots in the closeness to the IAC. The most common horizontal relation was “roots above IAC” (54%) followed by “roots lingual to IAC” (41.78%), “roots buccal to IAC” (3.42%), and “IAC between the roots” (0.68%). No significant differences in second and third molar roots and their contrasting teeth in the proximity to IAC. The older age group had significantly higher vertical measurements between third molar roots and IAC. There were significantly larger vertical measurements in the right third molar roots to IAC in males than females. Conclusions: These anatomical relationships are important clinical knowledge to avoid potential surgical injury to the inferior alveolar nerve.

Objectives: Canine retraction was accelerated by periodontal distraction or several surgical techniques depending on the concept that the greater surgical injury to alveolar bone, the greater biological response in the form of localized inflammatory reaction and bone remodeling, hence tooth movement acceleration. The present study aimed to compare between certain surgical techniques and periodontal distraction combined with interseptal bone reduction to accelerate canine distalization.Patients and Methods: A randomized split mouth clinical multi-operator study was performed on 30 orthodontic patients aged 15 years and above whose treatment procedures were planned for first premolar extractions and subsequent retraction of canines. Canines were distalized by surgery or distraction on one side and by conventional mechanics on the other side (the control side). Subjects were randomized equally into three canine retraction groups: Group I (multiple-osteoperforation MOPs); Group II (MOPs+corticotomy) and Group III (periodontal distraction). Canine retraction was carried out by power chain applying 150 g of force per side. Total time for complete canine retraction was determined and change in canine angulation was assessed using panoramic radiographs.Results: Regarding the time needed for complete canine retraction for all groups, the experimental side(surgical or distraction) showed a statistically significant lower mean value as compared with the non-surgical side. In other words, less than three months in Group I, about two months in Group II and less than one month in Group III, while more than four months in the conventional retraction side was taken for complete canine retraction. the mean canine angulation changes by degree was (11-15.2-23.2-8.1) degree for group I, II III and conventional group respectively.Conclusion: Canine retraction movement was accelerated effectively by MOPs, corticotomy and periodontal distraction techniques; the fastest of them was the periodontal distraction mechanics. However, it showed more distal tipping and more buccal inclination of the canine than MOPs, corticotomy or conventional canine retraction.

Focal defects in the annulus fibrosus (AF) of the intervertebral disc (IVD) arising from herniation have detrimental impacts on the IVD's mechanical function. Thus, biomimetic-based repair strategies must restore the mechanical integrity of the AF to help support and restore native spinal loading and motion. Accordingly, an annulus fibrosus repair patch (AFRP); a collagen-based multi-laminate scaffold with an angle-ply architecture has been previously developed, which demonstrates similar mechanical properties to native outer AF (oAF). To further enhance the mimetic nature of the AFRP, interlamellar (ILM) glycosaminoglycan (GAG) was incorporated into the scaffolds. The ability of the scaffolds to withstand simulated impact loading and resist herniation of native IVD tissue while contributing to the restoration of spinal kinematics were assessed separately. The results demonstrate that incorporation of a GAG-based ILM significantly increased (p 0.001) the impact strength of the AFRP (2.57 ± 0.04 MPa) compared to scaffolds without (1.51 ± 0.13 MPa). Additionally, repair of injured functional spinal units (FSUs) with an AFRP in combination with sequestering native NP tissue and a full-thickness AF tissue plug enabled the restoration of creep displacement (p = 0.134), short-term viscous damping coefficient (p = 0.538), the long-term viscous (p = 0.058) and elastic (p = 0.751) damping coefficients, axial neutral zone (p = 0.908), and axial range of motion (p = 0.476) to an intact state. Lastly, the AFRP scaffolds were able to prevent native IVD tissue herniation upon application of supraphysiologic loads (5.28 ± 1.24 MPa). Together, these results suggest that the AFRP has the strength to sequester native NP and AF tissue and/or implants, and thus, can be used in a composite repair strategy for IVDs with focal annular defects thereby assisting in the restoration of spinal kinematics.

STUDY DESIGN Preclinical study in rodents. OBJECTIVE To investigate changes in biomechanical properties of paraspinal muscles following a posterior spinal surgery in an animal model. SUMMARY OF BACKGROUND DATA Posterior spine surgery damages paraspinal musculature per histological and imaging studies. The biomechanical effects of these changes are unknown. METHODS 12 Sprague-Dawley rats were divided equally into sham and surgical injury (SI) groups. For sham, the skin and lumbodorsal fascia were incised at midline. For SI, the paraspinal muscles were detached from the vertebrae, per normal procedure. Thirteen weeks postsurgery, multifidus and longissimus biopsies at L1, L3, and L5 levels were harvested on the right. From each biopsy, three fibers and three to six bundles of fibers (∼10-20 fibers ensheathed in their extracellular matrix) were tested mechanically to measure their passive elastic modulus. The collagen content and fatty infiltration of each biopsy were also examined histologically by immunofluorescence staining. Nonparametric statistical methods were used with a 1.25% level of significance. RESULTS A total of 220 fibers and 279 bundles of fibers were tested. The elastic moduli of the multifidus and longissimus fibers and longissimus fiber bundles were not significantly different between the SI and sham groups. However, the elastic modulus of multifidus fiber bundles was significantly greater in the SI group compared to sham (SI median 82 kPa, range 23-284; sham median 38 kPa, range 23-50, P = 0.0004). The elastic modulus of multifidus fiber bundles in the SI group was not statistically different between spinal levels (P = 0.023). For histology, only collagen I deposition in multifidus was significantly greater in the SI group (median 20.8% vs. 5.8% for sham, P

Stress urinary incontinence (SUI) is a significant health concern for patients affected, impacting their quality of life severely. To investigate mechanisms contributing to SUI different animal models were developed. Incontinence was induced under defined conditions to explore the pathomechanisms involved, spontaneous recovery, or efficacy of therapies over time. The animal models were coined to mimic known SUI risk factors such as childbirth or surgical injury. However, animal models neither reflect the human situation completely nor the multiple mechanisms that ultimately contribute to the pathogenesis of SUI. In the past, most SUI animal studies took advantage of rodents or rabbits. Recent models present for instance transgenic rats developing severe obesity, to investigate metabolic interrelations between the disorder and incontinence. Using recombinant gene technologies, such as transgenic, gene knock-out or CRISPR-Cas animals may narrow the gap between the model and the clinical situation of patients. However, to investigate surgical regimens or cell therapies to improve or even cure SUI, large animal models such as pig, goat, dog and others provide several advantages. Among them, standard surgical instruments can be employed for minimally invasive transurethral diagnoses and therapies. We, therefore, focus in this review on large animal models of SUI.

It is possible that in the setting of increasing patient comorbidity and obesity, risk for surgical injury and need for reoperation is increasing. It is also possible that with differential uptake of evidence-based recommendations and increasing prevalence of risk factors such as obesity, risk for surgical site complications is increasing. The objective of this study was to evaluate trends in, risk factors for, and racial disparities related to cesarean complications. This repeated cross-sectional study evaluated cesarean deliveries in the 2002–2014 National Inpatient Sample for women age 15–54. The primary outcome was a cesarean surgical complication composite including (i) surgical injuries, (ii) reoperation, and (iii) surgical site complications. Surgical injuries, reoperation, and surgical site complications were additionally evaluated individually as outcomes. Univariable and multivariable log linear regression models including demographic, clinical, and hospital factors were performed to assess risk for outcomes with unadjusted and adjusted risk ratios (aRR) with 95% confidence intervals (CI) as measures of association. Temporal trends were estimated using average annual percentage change from a joinpoint regression model. A stratified analysis was performed restricted to non-Hispanic black women. Data was weighted to provide national estimates. A total of 16.2 million estimated cesarean deliveries (3.2 million unweighted cesarean deliveries) from 2002 to 2014 were included in this analysis. The prevalence of the cesarean surgical complication composite was 1.14%, surgical site complications occurred in 0.60%, surgical injuries in 0.49%, and reoperations in 0.10%. Comparing the end of the study (2012–2014) to the beginning of the study (2002–2003), adjusted risk for the composite was similar (aRR 0.93, 95% CI 0.92, 0.95). In comparison, surgical site complication risk was lower at the end of the study (aRR 0.77, 95% CI 0.75, 0.79) while risks for surgical injury (aRR 1.18, 95% CI 1.15, 1.22) and reoperation (1.18, 95% CI 1.10, 1.26) were higher. Non-Hispanic black women were at increased risk for surgical site complications (aRR 1.83, 95% CI 1.80, 1.87) and reoperation (aRR 1.44, 95% CI 1.37, 1.51), but not surgical injury (aRR 0.99, 95% CI 0.97, 1.02). In analyses stratified for non-Hispanic black women, there was a reduction in risk for surgical site complications at the end of the study period compared to the beginning similar to the primary analysis (aRR 0.76, 95% 0.72, 0.81) with a modest decrease in overall risk for the composite outcome (aRR 0.85, 95% CI 0.81, 0.89). A decrease in risk for surgical site complications was offset by slightly increased risk for surgical injury and reoperation in adjusted analyses. Among non-Hispanic black women, surgical site complication risk decreased proportionately with this group still at significantly higher overall risk.

Objective: To investigate the effects of the mechanical trauma to the round window, a model electrode inserted into the scala tympani on the cochlear reserve, and the efficacy of topical steroids in preventing hearing loss. Materials and Methods: 21 male Wistar Albino rats were equally categorized into three groups. In all groups an initial mechanical injury to round window was created. Only subsequent dexamethasone injection was administrated into the cochlea in the subjects of group 2 while a multichannel cochlear implant guide inserted into the cochlea prior to dexamethasone administration for group 3. Distortion product otoacoustic emissions (DPOAEs) were obtained prior to and immediately after the surgical injury, eventually on postoperative seventh day (d 7). Mean signal/noise ratios (S/Ns) obtained at 2000, 3000, and 4000 Hz were calculated. Data sets were compared with non-parametric statistical tests. Results: The early intraoperative mean S/Ns were significantly less than preoperative measurements for group 1 and 2; however, preoperative and postoperative d 7 average S/Ns did not differ. There was statistically significant difference between preoperative, intraoperative and postoperative d 7 average S/Ns for group 3. Conclusion: We observed that hearing was restored approximately to the preoperative levels following early postoperative repair. However, an electrode insertion into the cochlea via round window subsequent to mechanical trauma seems to cause a progressive hearing loss. Therefore, a special care must be taken to avoid the injury to the round window membrane in the course of the placement of a cochlear implant electrode and surgery for the chronic otitis media.

Introduction: Enhanced Recovery After Surgery (ERAS) protocol is a perioperative multimodal service program designed to achieve a faster surgical recovery period and a better outcome, the key in reducing morbidity in surgery is by reducing the “surgical injury” and reducing the body’s stress response caused by the surgery. The success of the ERAS protocol depends on the interpretation and collaboration of the multidisciplinary team, therefore though the protocol is carried out in a hospital that has sufficient facilities and resources, the obstacle in the implementation of ERAS can still happen. The implementation of ERAS protocol in the non-permanent hospital service facility becomes a challenge in itself. Case Reports: From the two case reports of the implementation of ERAS protocol in the Ksatria Airlangga Floating Hospital (RST-KA) it is obtained that the key success of the anesthesia in ERAS protocol above lies on the administration of opioid-sparring therapy where it will reduce the use of opioid. Although there are many obstacles obtained in the RST-KA, the use of ERAS protocol can be conducted by making effective use of opioid-sparring combined with the administration of multimodal analgesia. Conclusion: Therefore, it can be concluded that the ERAS protocol can be applied in the social service concept in the non-permanent health facility.

Serum anti-Müllerian hormone (AMH) levels decrease after surgical treatment of ovarian endometrioma. This is the main reason that surgery for ovarian endometrioma endometriosis is not recommended before in vitro fertilization, unless the patient has severe pain or suspected malignant cysts. Furthermore, it has been suggested that ovarian endometrioma itself damages ovarian reserve. This raises two important challenges: (1) determining how to prevent surgical damage to the ovarian reserve in women with ovarian endometrioma and severe pain requiring surgical treatment and (2) deciding the best treatment for women with ovarian endometrioma without pain, who do not wish to conceive immediately. The mechanisms underlying the decline in ovarian reserve are potentially induced by both ovarian endometrioma and surgical injury but the relative contribution of each process has not been determined. Data obtained from various animal models and human studies suggest that hyperactivation of dormant primordial follicles caused by the local microenvironment of ovarian endometrioma (mechanical and/or chemical cues) is the main factor responsible for the decreased primordial follicle numbers in women with ovarian endometrioma. However, surgical injury also induces hyperactivation of dormant primordial follicles, which may further reduce ovarian reserve after removal of the endometriosis. Although further studies are required to elucidate the mechanisms underlying diminished ovarian reserve in women with ovarian endometrioma, the available data strongly suggests the need to prevent/minimize hyperactivation of dormant primordial follicles, regardless of whether surgery is performed, for better clinical management of ovarian endometrioma.

Objective This quality improvement (QI) initiative was designed to identify gaps between evidence-based or hospital recommendations for trial of labour after cesarean delivery (TOLAC) labour management and clinical practice. Methods Viable, singleton pregnancies from January 1, 2016, to December 31, 2018, undergoing TOLAC were extracted from the electronic medical record. Sixty randomly selected charts were reviewed for (1) consent, (2) induction methods, (3) oxytocin use, (4) continuous fetal monitoring, (5) admission indication, (6) examination regularity, (7) duration of dystocia before decision to perform cesarean delivery (CD), and (8) maternal complications. Results The institutional vaginal birth after cesarean rate was 71%. Documented consent to TOLAC on admission was present in 50% of cases. Oxytocin augmentation was used in 38% of cases, and the median maximum dose was 4 mU/min (interquartile range [IQR] 3–7.5 mU/min). Delays in initiating oxytocin were identified in 47% of those patients. Decisions to deliver by cesarean were made after a median time of 5 hours and 40 minutes (IQR 3 hours and 30 minutes to 6 hours and 35 minutes) of failure to progress despite adequate contractions. After this decision, median time to delivery was 1 hour and 11 minutes (IQR 57 minutes to 2 hours and 16 minutes). Complications included postpartum hemorrhage (5%) and chorioamnionitis (6.7%). Surgical injury occurred in 10% of intrapartum CD. Peripartum complications were associated with delay in oxytocin implementation (χ2 (1) = 9.80; P Conclusion Areas for QI were identified in (1) consent, (2) duration of dystocia before decision to proceed with CD and delay to CD, and (3) peripartum complications. We recognize the potential use of this as a tool to identify areas for QI and prospective study.

Rodent models that experience a mechanical injury to the facet joint have had contradicting results regarding the degree of osteoarthritis that the injured joint experiences. This thesis sought to answer if this disagreement was caused by surgical injury to the paraspinal multifidus muscle. It was expected that muscle and joint injury would drive changes in the muscle architecture, collagen content, facet joint transverse plane angle and characteristics of osteoarthritis. No consistent changes in any muscle measures were seen outside of the injured multifidus muscle, which had a decrease in mass and fascicle length while the collagen content increased. No changes in the facet joint angles or osteoarthritis statuses were seen. It is suspected that the degree of fibrosis for the injured muscle may have inhibited osteoarthritis processes. Future work should explore the role of paraspinal muscles in facet joint osteoarthritis using nonsurgical models. Ontario Government via the Ontario Graduate Scholarship, The National Science and Engineering Research Committee 2021-12-14

Purpose: To report our findings in a case of bilateral Mooren's ulcer that developed after filtering surgeries using the EX-PRESS glaucoma filtering device (EX-PRESS surgery). Patients and methods: A 71-year-old Japanese man with primary open angle glaucoma underwent EX-PRESS surgery first in his left eye and 1 month later in his right eye. He developed Mooren's ulcer in his right eye at 7 months and in his left eye at 10 months after the initial EX-PRESS surgery. Systemic examinations showed no collagen vascular disease, and he did not have a history of bacterial or viral infections. He was not allergic to metallic materials. Before the EX-PRESS surgery, he had underdone cataract surgery combined with trabeculotomy in both eyes, and a reoperation of trabeculotomy in his left eye. He had not developed Mooren's ulcer after these surgeries. The Mooren's ulcer after the EX-PRESS surgery was treated with oral prednisolone (30 mg tapering) in combination with topical 0.1% betamethasone sodium. The ulcers were responsive and healed well in three months. Conclusions: The EX-PRESS devices were most likely the cause of the Mooren's ulcers considering that they were located close to the site of EX-PRESS insertion and no peripheral corneal ulcer developed after prior intraocular surgeries. Keywords: Mooren's ulcer, Glaucoma implant surgery, EX-PRESS glaucoma filtering device, Autoimmune reaction, Surgical injury

Background. Gynecomastia is one of the most famous and common paraneoplastic syndromes. With the growth of equipment clinics with modern diagnostic equipment, including the CT, increases the detection of breast pathology in men. There is the need for a correct interpretation of the data about the state of male breast by radiologists, and the attending physician, oncologist, mammologist, urologist, endocrinologist. The purpose of the study to identify possible differences in frequency and radiation pattern of gynecomastia in patients with cancer and without it and also to follow the dynamics of the development of gynecomastia in patients with cancer, to identify the probable causes of the progression of gynecomastia in patients with cancer. Materials and methods. It's data of 400 chest CT of men who were screened and treated for the different oncological pathology in Voronezh regional clinical oncological hospital in 2013-2015. And also data of 150 chest CT of men who were screened and treated for the various diseases (excluding oncological diseases) in the Voronezh regional clinical diagnostic center and Kursk regional clinical hospital in 2013-2015 was used. Results. The data of the frequency of occurrence various types of gynecomastia in patients with cancer pathology and without it was obtained. The frequency of occurrence of gynecomastia in patients with cancer depending on the localization and morphology of tumor was analyzed. The dynamics of the gynecomastia in patients with cancer was tracked and possible causes of its progression in patients in this group were identified. Conclusions 1. Gynecomastia is a frequent pathology revealed by chest CT in men as suffering from oncological disease and without it. Gynecomastia significantly more often found in patients suffering from prostate adenocarcinoma and renal cell carcinoma. Surgical injury may be one of the reasons for the development of gynecomastia. Feature of gynecomastia in patients with cancer is its asymmetry. When the detection of asymmetrical gynecomastia by chest CT is recommend the further examination of patient to exclude him cancer pathology, special attention should be paid to the prostate gland and the kidneys. Upon detection of the progression of gynecomastia in a patient with a history of cancer need further examination to exclude cancer pathology progression.

The paper describes a method for three-dimensional printing of сustom-made interbody cages accounting for biomechanical parameters of the intervertebral disc (anteroposterior size, anterior and posterior disc heights), which provides the implant with unique characteristics. An example of using custom-made cages providing optimal conditions for the formation of interbody bone-metal block due to the extra tight fit of the combined implant is given. It is shown that custom-made cages have a beneficial effect on the spine support recovery time, significantly reduce the surgical injury, and shorten the time of surgery. The manufacturing of each developed implant which has its own form and architecture is not a serial but a piece production not requiring additional registration procedure. The use of custom-made spinal cages allows optimizing the process of surgical treatment and improving short- and medium-term results.

Surgical wound infections prompt antagonistic patient results, including delayed hospitalization and demise. Wound infection happens with every entry point, however demonstrated procedures exist to diminish the hazard of surgical injury diseases. Specifically, enhanced adherence to prove that based deterrent measures identified with fitting antimicrobial prophylaxis can diminish the rate of surgical wound infection. Various patient-related and technique related components impact the danger of surgical injury disease, and henceforth counteractive action requires a package approach, with deliberate consideration regarding numerous hazard factors, to diminish the hazard of bacterial pollution and enhance the patient's defences. Forceful surgical debridement and successful antimicrobial treatment are expected to enhance the treatment of surgical wound infections.

Benign biliary strictures (BBSs) are commonly caused by surgical injury, chronic pancreatitis, and inflammatory cholangiopathies. Although advanced imaging tests and tissue acquisition methods have been developed for evaluation of indeterminate biliary strictures, differentiation of BBSs from biliary malignancies remains a challenge to clinicians. The majority of BBSs have good response to nonsurgical treatment and surgical intervention mainly serves as a rescue when nonsurgical approaches fail. Endoscopic management is a safe, effective, and less-invasive treatment for BBSs compared with other approaches. Endoscopic biliary stricture dilation followed by placement of multiple plastic stents has been the first-line choice with good long-term ductal patency. Recently, covered self-expanding metal stents (CSEMSs) has been increasingly used in the management of BBSs with similar effectiveness but easier deployment, fewer endoscopic sessions compared with plastic stents. Moreover, other technologies are emerging in the diagnosis and management of BBSs. To assist clinicians in managing BBSs, the Asia-Pacific ERCP Club (APEC) has developed this statement through a systematic review of the literature.

Objective To determine the effect of alveolar decortication on orthodontically induced root resorption. Materials and Methods A total of 24 male Wistar rats (14 week old) were used. The rats were randomly divided into one of the following three groups: group 1 (control group), orthodontic tooth movement (OTM) for 2 weeks; group 2, OTM for 2 weeks + two alveolar decortications (2AD); group 3, OTM for 2 weeks + four alveolar decortications (4AD). The first molar was moved mesially for 2 weeks. Micro computed tomography was used to analyze root volume. In addition, histological sections were stained with Tartrate Resistant Acid Phosphatase (TRAP) to quantify the osteoclast number. Results The buccal root volume in OTM + 4AD group was decreased by 8.92% and 6.11% when compared with the OTM-only group and OTM + 2AD group, respectively. Similarly, the other four root volumes in the OTM + 4AD group was decreased by 8.99% and 5.24% when compared with the OTM-only group and OTM + 2AD group, respectively. There was a decrease in buccal root density in the OTM + 4AD group by 4.66% and 3.56% when compared with the OTM-only group and the OTM + 2AD group, respectively. In addition, there was an increase in the number of osteoclasts by 195.73% and 98.74% in OTM + 4AD group in comparison with the OTM and OTM + 2AD group. Conclusions The amount of orthodontically induced root resorption was positively correlated with the extent of surgical injury used to accelerate orthodontic tooth movement.

Typical etiologies of vesicovaginal fistula (VVF) include obstructed labor, iatrogenic surgical injury, pelvic irradiation and cancer invasion. VVF caused by cystocele are very rare. To date, there are no documented cases in Japanese literature.A 74-year-old woman presented with near total incontinence. On physical examination, she was found to have severe cystocele and pressure necrosis of anterior vaginal wall, which caused partial breakdown of vaginal mucosa and VVF. She underwent vesicovaginal fistula repair using transvaginal and transabdominal approaches. Catheter drainage was performed for 10 days and postoperative cystogram showed no sign of leakage. She is currently symptom-free at 55 months.

Objectives This quality improvement (QI) initiative was designed to identify gaps between evidence-based and/or hospital recommendations for TOLAC labour management, and clinical practice. Methods Viable, singleton pregnancies from January 1, 2016 to December 31, 2018 undergoing TOLAC were extracted from the electronic medical record. Sixty (60) randomly selected charts were reviewed for 1) consent 2) induction methods 3) oxytocin use 4) continuous fetal monitoring 5) admission indication 6) exam regularity 7) duration of dystocia prior to decision for cesarean section (CS) 8) maternal complications. Results Institutional VBAC rate was 71%. Documented consent to TOLAC on admission was present in 50% of cases. Oxytocin augmentation was used in 38% of cases and the median max dose was 4 [IQR 3-7.5] mU/min. Delays in initiating oxytocin were identified in 47% of those patients. Decisions to deliver by CS were made after a median time of 5h 40 min [IQR 3h 30m – 6h35m] of failure to progress despite adequate contractions. After this decision, median time to delivery was 1h 11m [IQR 57m–2h 16m]. Complications included post-partum hemorrhage (5%) and chorioamnionitis (6.7%). Surgical injury occurred in 10% of intrapartum CS. Peri-partum complications were associated with delay in oxytocin implementation ((1) = 9.80, p Conclusions Areas for QI were identified in 1) consent, 2) duration of dystocia prior to decision for CS and delay to CS delivery, 3) peri-partum complications. We recognize the potential use of this as a tool to identify areas for QI and prospective study.

The neurotoxicity of general anesthetic drugs still appears as a relevant interdisciplinary problem. All general anesthetics that are currently in use exhibit a neurotoxic effect on the brain at all stages of its development. It is impossible to evaluate the negative impact of general anesthetics without considering the effect of surgical injury, intraoperative complications, pain syndrome, main and concomitant diseases. We report a case of hypoxic brain injury in the early postoperative period in a child with severe comorbidities and perinatal complications in anamnesis.

Postoperative paralysis of the vocal cords resulting from intraoperative surgical injury of the recurrent laryngeal nerve is one of the most serious complications of elective thyroid surgery. The chance of injury is reduced by using intraoperative neuromonitoring (IONM). This educational report describes a case of IONM failure resulting from residual muscle relaxation that was restored by administration of sugammadex. It discusses possible pharmacology explanations and provides recommendations for how to prevent this situation in daily practice.

This study provides novel insight into the process by which surgical injury places the intestinal epithelium at risk for colonization by pathogenic microbes and impairment of its regenerative capacity via loss of its microbiota. We show that fecal transplant restores crypt homeostasis in association with repopulation of the microbiota within cecal crypts., Cecal crypts represent a unique niche that are normally occupied by the commensal microbiota. Due to their density and close proximity to stem cells, microbiota within cecal crypts may modulate epithelial regeneration. Here we demonstrate that surgical stress, a process that invariably involves a short period of starvation, antibiotic exposure, and tissue injury, results in cecal crypt evacuation of their microbiota. Crypts devoid of their microbiota display pathophysiological features characterized by abnormal stem cell activation as judged by leucine-rich repeat-containing G protein-coupled receptor 5 (Lgr5) staining, expansion of the proliferative zone toward the tips of the crypts, and an increase in apoptosis. In addition, crypts devoid of their microbiota display loss of their regenerative capacity as assessed by their ability to form organoids ex vivo. When a four-member human pathogen community isolated from the stool of a critically ill patient is introduced into the cecum of mice with empty crypts, crypts become occupied by the pathogens and further disruption of crypt homeostasis is observed. Fecal microbiota transplantation restores the cecal crypts’ microbiota, normalizes homeostasis within crypts, and reestablishes crypt regenerative capacity. Taken together, these findings define an emerging role for the microbiota within cecal crypts to maintain epithelial cell homeostasis in a manner that may enhance recovery in response to the physiological stress imposed by the process of surgery. NEW & NOTEWORTHY This study provides novel insight into the process by which surgical injury places the intestinal epithelium at risk for colonization by pathogenic microbes and impairment of its regenerative capacity via loss of its microbiota. We show that fecal transplant restores crypt homeostasis in association with repopulation of the microbiota within cecal crypts.

Purpose: To establish determining factors for fast corneal sensitivity (CS) recovery after pterygium excision. Methods: Thirty-two eyes of 14 males and 18 females with primary nasal pterygium were recruited. Differences in CS (in the 4 quadrants and the center using a Cochet–Bonnet esthesiometer), pterygium corneal area (PCA), tear osmolarity, tear break-up time, Schirmer test, and ocular symptoms were analyzed before and 1 month after lesion excision. The relationship between CS recovery (difference between the 2 time points; CS1 – CS0) and the other features was assessed. Results: All the studied locations exhibited normal (6 cm) or near-normal mean CS at the 2 time points, except a tendency for moderate hypoesthesia in nasal CS0 (median 4.5; range: 1.5–6.0 cm). Point by point comparison revealed significant postoperative improvements in nasal location (P = 0.008; Wilcoxon signed-rank test) with normal values in 17 eyes (53%) and a median CS1 = 5.0 cm (2.5–5.5 cm) in 15 eyes with no complete recovery. No significant correlation was found between CS0 and the studied variables, and CS1 was only significantly correlated with PCA (rho: -0.441; P < 0.05). CS recovery also showed significant correlation with PCA (rho = -0.516; P < 0.01). Conclusions: CS recovery after pterygium excision showed important variability, and the only studied factor that seems to be determinant could be PCA. It would be advisable to operate when the lesion is relatively small, with lower surgical injury and faster and complete recovery, thus protecting ocular surface homeostasis.

A new method is implemented in order to measure the concentration of CO2 and inhalation anesthetic sevoflurane eliminated through the skin during surgery. The concentration of inhalation anesthetic has been measured during general combined anesthesia (sevoflurane, fentanyl) and total intravenous anesthesia (propofol, fentanyl). The dependence of the concentration of CO2 and the inhalation anesthetic from the relaxation of smooth muscles in the walls of blood vessels under the effect of sevoflurane and propofol and on the stress response to surgical injury has been revealed for the first time.

Purpose of review The purpose of this review is to highlight new research findings in the complex bidirectional crosstalk that occurs between the intestinal microbiome and the host immune system in the context of surgical recovery and outcomes. Recent findings Significant evidence has been generated emphasizing the central role of the intestinal microbiome on surgical outcomes such as wound healing, surgical site infections and anastomotic leak. Current preventive strategies, including the use of some parenteral antibiotics, may actually exacerbate the problem by selecting for drug-resistant pathogens. Summary A delicate balance exists between the human host and its microbial counterparts that is directly related to postsurgical healing. This balance can be easily altered in favor of the pathogen through perioperative and surgical interventions leading to intestinal dysbiosis and loss of colonization resistance. Current strategies to prevent infectious complications with the escalating use of broader and more powerful antibiotics are not an evolutionarily stable strategy. A more complete understanding of the ecological and molecular interactions of the host with its microbiome is necessary to uncover new therapeutic strategies that preserve the composition and function of the intestinal microbiome and constrain virulent pathogens through the course of surgical injury.

Objective The purpose of this investigation was to evaluate the therapeutic efficacy of superpulsed, low-level laser therapy (SLLLT) on neurosensory recovery of the inferior alveolar nerve (IAN) after oral surgical injury. Background data A survey of the literature reveals the uncertainty of outcomes for the surgical management of IAN injury and the efficacy of low-level laser therapy in the treatment of IAN injury. Methods In this study, the authors report the results for SLLLT in 57 patients affected by paresthesia of the lip, chin, gingival, and buccal regions. Each patient was subjected to 10 laser treatments, once a week, with a GaAs diode laser. Clinical neurosensory tests (soft touch, 2-point discrimination, pin prick, thermal test) and the visual analogue scale were used before every treatment to evaluate the extent of neurosensory recovery. Results The authors' results demonstrate that 83.3% of the patients had a significant neurosensory recovery, as evident in the objective and subjective tests. Conclusion The results reported in this study indicate that SLLLT has the potential to improve neurosensory recovery in patients with IAN paresthesia.

Background: Although pleurodesis is usually used to reduce the recurrence rate for primary spontaneous pneumothorax (PSP) in surgery, existing techniques cannot meet the higher requirements of little surgical injury and less relapse. Hence, we developed a new pleurodesis technique and named multipoint pleura cautery. Aim: In this study, we aimed to investigate the effectiveness and outcomes of the uniportal video-assisted thoracoscopic surgery C-shaped pleura cautery in the surgical treatment of PSP. To the best of our knowledge, this is a new surgical technique for pleurodesis and must be of concern. Patients and Methods: The medical records of 20 patients undergoing surgery for C-shaped pleura cautery between 2015 and 2017 were reviewed. The patients were evaluated with regard to age, gender, body mass index, smoking habit, operation time, duration of hospitalization, post-operative pain and follow-up. Results: We have performed a bullectomy combined C-shaped pleura cautery for 20 patients with PSP from January 2016 to December 2017. None of the patients suffered post-operative bleeding and haematothorax complications, and one was ipsilateral relapsed 5 months after surgery. The lung computed tomography showed that recurrence of pneumothorax was due to air leakage in the right lower lung, and there was no air leakage at the site where pleurodesis had been performed. Conclusions: Although this technique requires further investigation, it may be a useful method of pleurodesis.

The aim of the study was to determine the efficacy of using digital technologies in patients with post-traumatic deformities of the zygomatico-orbital complex (ZOC) by comparing the results with the conventional methods of surgical treatment. Materials and Methods. The article summarizes treatment results of 231 patients with ZOC injuries who underwent surgery at the clinical facilities of Privolzhsky Research Medical University (Nizhny Novgorod) in 2011–2019. There were treated 44.2% (102/231) of patients with post-traumatic deformities of ZOC, including 38.2% (39/102) with post-traumatic defects and deformities of the orbital floor. Based on clinical and radiological planning of surgical operations, the patients were divided into two groups: group 1 included patients who underwent surgery without preoperative virtual planning (54.9% (56/102) of cases), group 2 included patients who underwent virtually planned surgical interventions (45.1% (46/102) of cases). There were 22 and 17 patients with orbital deformities in groups 1 and 2, respectively. Results. The optimal restoration of ZOC anatomy was observed in 75% (42/56) of patients in group 1 and 93.5% (43/46) of patients in group 2. During reconstruction of the orbital floor in patients of group 1, successful results were achieved in 68.2% (15/22) of cases and 88.2% (15/17) in group 2, various complications were observed in the rest of cases. Based on the analysis of surgical treatment results, there was developed a personalized approach to manufacturing of zygomatic bone and orbital floor implants using computer modeling and 3D printing technologies. Conclusion. In contrast to the conventional methods, the use of digital technologies in the surgical treatment of post-traumatic deformities of ZOC allows avoiding the problematic issues of implant positioning and the development of complications during reconstruction, significantly reducing surgical injury and improving patient rehabilitation.

Trachea and carina resection and reconstruction is a difficult surgical technique. In the past, such procedures were completed via large incisions (Pearson FG, Thompson DW, Weissberg D, Simpson WJ, Kergin FG, Ann Thorac Surg 18:16–29, 1974) and, consequently, patients’ time to make a full recovery was much longer. In addition, the high potential for postoperative complications have led to many thoracic surgeons avoiding performing these procedures. With the advances of surgical techniques and equipment (Jiao W, Zhu D, Cheng Z, Zhao Y, Ann Thorac Surg 99:e15–7, 2015), including advances in the management of anesthesia, the implementation of tracheal and carina resection/reconstruction is now feasible under complete video-assisted thoracoscopic surgery (c-VATS). For surgeons with extensive VATS experience, the uniportal technique is also a feasible and safe choice that further reduces surgical injury and may accelerate postoperative recovery. Here we introduce two cases: one tracheal and one carinal resection/reconstruction performed under the uniportal VATS technique.

Pancreatic tumors and their surgical resection are associated with significant morbidity and mortality, and the biomarkers currently used for these conditions have limited sensitivity and specificity. Because calprotectin and calgranulin C serum levels have been demonstrated to be potential biomarkers of certain cancers and complications of major surgery, the levels of both proteins were tested in the current study in patients with benign and malignant pancreatic tumors that were surgically removed. The baseline serum levels and kinetics of calprotectin and calgranulin C during the 7-day postoperative period were evaluated with immunoassays in 98 adult patients who underwent pancreatic surgery. The baseline serum levels of calprotectin and calgranulin C in patients with malignant (n=84) and benign tumors (n=14) were significantly higher (p<0.01) when compared to those in the healthy controls (n=26). The serum levels of both proteins were also significantly (p<0.05) higher in patients with benign tumors than in those with malignant tumors. After surgery, the serum levels of calprotectin and calgranulin C were significantly (p<0.01) higher than their baseline values, and this elevation persisted throughout the seven days of the follow-up period. Interestingly, starting on day 1 of the postoperative period, the serum levels of both proteins were significantly (p<0.05) higher in the 37 patients who developed postoperative pancreatic fistulas (POPFs) than in the patients who had uneventful recoveries (n=61). Moreover, the serum levels of calprotectin and calgranulin C demonstrated a significant predictive value for the development of POPF; the predictive values of these two proteins were better than those of the serum level of C-reactive protein and the white blood cell count. Taken together, the results of this study suggest that calprotectin and calgranulin C serum levels are potential biomarkers for pancreatic tumors, surgical injury to the pancreatic tissue and the development of POPFs.

Overshooting trocar insertion in Iaparoscopic surgery has been extensively cited as a major cause of surgical injury. The complexity and extensive insertion force required of the current handheld insertion method increases the risk of overshooting and is difficult for novice and female operators. Hence, we developed a trocar insertion device to make the procedure easier and safer. The device is designed so it is easy to handle and assemble. It used negative pressure and pneumatic cylinders to lift the abdominal wall and two motors to drive the trocar insertion. In addition, we interpreted the characteristics of the insertion force and developed an algorithm to detect whether the trocar is properly inserted. By monitoring changes in the insertion force with this device, the trocar insertion can be stopped automatically and immediately. The development of this device has realized the automation of trocar insertion. It reduces the demand on operators and improves the safety of the procedure.