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Purpose: The aim of the study was to explore long-term experiences of transanal irrigation (TAI) in patients with major low anterior resection syndrome (LARS)., Methods: The study included a qualitative and quantitative analysis of patients who developed major LARS after rectal cancer surgery between 2016 and 2019 and have undergone treatment with TAI. The patients received questionnaires. Mean scores were calculated with time-to-deterioration. Individual semi-structured interviews were performed and analyzed, according to Graneheim and Lundman with patients who performed TAI regularly for more than one year., Results: In total 28 out of 39 patients responded to the questionnaires and 16 patients participated in the interviews. At mean 6-years follow-up, a 9.4 points difference in mean LARS score was obtained, (21.2 vs. 30.7) indicating less LARS symptoms in favor of the TAI treatment. Patients in the TAI group used less loperamide compared to the control group (36% vs. 79%). The use of bulky agents was similar. The interview text rendered into three main categories: regaining control in everyday life, need for structure and planning and becoming familiar with the procedure., Conclusions: Treatment with TAI showed the potential to improve the quality of life of patients with major LARS. The improvements in their general well-being were valued over adjustments and time spent on TAI., Implications for Cancer Survivors: Bowel dysfunction remains after 6-years with lower LARS scores favoring the TAI treatment. In the absence of a definitive treatment, survivors of rectal cancer coping with LARS have shown appreciation of the TAI treatment., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by the Local Ethics Committee of Stockholm (Etikprövningsmyndigheten) (2023-01438-02, 2017/551 − 31 and 2019–04398). Informed consent was obtained from the patients to participate in the study. The study adhered to the requirements of the Helsinki declaration and the principles of Good Clinical Practice (GCP). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

The global increase in urolithiasis prevalence has led to a shift towards minimally invasive procedures, such as retrograde intrarenal surgery, supported by advancements in laser technologies for lithotripsy. Pulsed lasers, particularly the holmium YAG and the newer thulium fiber laser, have significantly transformed the management of upper urinary tract stones. However, the use of high-power lasers in these procedures introduces risks of heat-related injury. Laser lithotripsy works through photothermal and photomechanical effects to fragment stones, but up to 96% of the laser energy is converted into heat, increasing the risk of thermal damage to the surrounding urothelial mucosa. Studies show that even at low-power settings, intrarenal temperatures can exceed the threshold for cellular injury, particularly in confined spaces like the ureter. This narrative review explores strategies to mitigate thermal injury, including optimizing laser settings, improving irrigation flow rates, and incorporating novel methods such as cold irrigation, controlling outflow resistance, and using suction. Understanding these approaches is crucial to enhancing patient safety during high-power laser lithotripsy procedures., Competing Interests: Sung Kyu Hong has been the Editor-in-Chief of Investigative and Clinical Urology since 2025. The other author has nothing to disclose., (© The Korean Urological Association.)

Objective: The implications of saline flushing of the radial sheath have not been studied in terms of radial artery occlusion. We aimed to investigate radial artery patency outcomes after the saline flush of the radial sheath., Methods: In this prospective observational study, patients were selected to receive either radial sheath flushing with 10 mL of saline after pulling the sheath to one-third of its length (Group 1) or standard care (Group 2) after removal of the catheter sheath as per physician discretion. Radial artery patency was assessed by Doppler ultrasound at 24 h and 30 days after the procedure., Results: A total of 2877 patients were enrolled in the study, with 1340 receiving radial sheath flushing and 1537 receiving standard care. At 24 h after the procedure, the incidence of radial artery occlusion was significantly lower in the radial sheath flushing group compared to the standard care group (4.4% vs 12.6%, p  = 0.027). This difference persisted 30 days after the procedure (6.1% vs 15.8%, p  = 0.015). Radial sheath flushing was independently associated with a lower risk of radial artery occlusion 30 days after the procedure, after adjusting for potential confounders (OR 0.375, 95% CI 0.18-0.77, p  = 0.008)., Conclusion: In conclusion, this prospective study provides evidence to support the use of radial sheath flushing after coronary intervention via the radial artery as a simple and effective strategy for reducing the risk of radial artery occlusion without increasing the risk of other adverse outcomes., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The optimal temperature of irrigation solution in patients undergoing PCNL is still unclear. Accordingly, this study aims to investigate the effects of different irrigation solution temperatures (cold/room temperature irrigation fluid versus warm/body temperature fluid). Our primary endpoint was hypothermia rate. Secondary outcomes were shivering rate, mean temperature decrease, mean patient final temperature, blood loss, and operative time., Evidence Acquisition: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were searched in November 2023. Among 299 studies screened, eight were selected for full-text review, resulting in four randomized clinical trials that fit inclusion criteria and desired outcomes. Studies selection and data extraction were performed by multiple reviewers and a random-effects model was used for pooling of data., Evidence Synthesis: The primary outcome, hypothermia rate, showed a significant statistical difference between groups, occurring less frequently in the experimental group (35-37 ºC) than in the cold/room temperature irrigation group (RR 0.64;95%CI 0.46, 0.89; P<0.008; I 2 =33%). Secondary outcomes such as shivering rate (RR 0.46; 95%CI 0.31, 0.67; P<0.0001; I 2 =0%) and mean final temperatures (MD 0.43; 95%CI 0.12, 0.75; I 2 =82%) also showed statistically significant differences between groups, favoring the irrigation with heated fluid., Conclusions: There was a decreased rate of hypothermia and shivering among patients undergoing PCNL with warm irrigation fluid. Mean final temperatures were also higher in the experimental group. As to blood loss, mean hemoglobin decrease showed no statistically significant difference between groups, prompting further investigation of the influence of Irrigation solution temperature on blood loss volume.

Competing Interests: Disclosures The authors have no conflicts of interest to disclose.

Background: Maintaining an adequate temperature at the target site is essential for effective ablation. We hypothesized that a tissue temperature-controlled (T-Con) catheter for cavotricuspid isthmus (CTI) ablation could improve the procedural ablation parameters., Purpose: To evaluate the efficacy and safety of the T-Con (DiamondTemp™) catheter for CTI ablation compared with non-irrigation (Non-Irri) and irrigation (Irri) catheters., Methods: We analyzed 150 patients who underwent prophylactic CTI ablation combined with pulmonary vein isolation. The Non-Irri, Irri, and T-Con catheter groups comprised 50 patients each, and the ablation procedural parameters and complications were compared between these groups., Results: There were no significant differences in clinical background characteristics among the three groups. The Kruskal-Wallis and post hoc tests demonstrated that the T-Con group showed the lowest total radiofrequency energy delivery time among the three groups (median [25 and 75 percentiles]: 340 [209, 357], 147 [100, 199], and 83 [61, 109] s, respectively in the Non-Irri, Irri, and T-Con groups; T-Con versus Non-Irri, p < .01; T-Con versus Irri, p < .01). The total procedural time and acute reconnection rate in the T-Con group (264 s and 4%, respectively) were lower than those in the Non-Irri group (438 s and 24%) but were similar to those in the Irri group (268 s and 6%). No significant complications were observed in any group., Conclusions: The T-Con catheter achieved a short energy delivery time and a low acute reconnection rate, indicating its potential as an alternative catheter for CTI ablation., (© 2024 Wiley Periodicals LLC.)

Background: Antibiotic implant irrigation is increasingly used to prevent deep infection after implant-based breast reconstruction. However, there is limited evidence of the clinical effect. In this study, the authors compare the risk of a deep infection in a Danish population of women who received antibiotic implant irrigation with either gentamicin or vancomycin, or no irrigation., Methods: The authors retrospectively reviewed consecutive patients undergoing all types of breast reconstruction with implants at Rigshospitalet and Herlev Hospital, Denmark, from 2010 to 2019. Logistic regression was used to compare the risk of deep infection between no irrigation and irrigation with gentamicin or vancomycin, and to account for the difference in risk between patient subgroups and risk factors., Results: The authors included 1508 patients who received antibiotic irrigation with gentamicin (500 patients), vancomycin (304 patients), or no irrigation (704 patients). The univariable risk analysis showed a significant decreased risk of deep infection using gentamicin irrigation compared with no irrigation (OR, 0.58; P < 0.05). However, when adjusting for risk factors for infection, there was no significant decrease in the risk of infection when using gentamicin (OR, 0.90; P = 0.71) or vancomycin (OR, 1.0; P = 0.99) compared with the control group., Conclusions: The authors found no significant effect of using antibiotic implant irrigation after isolating it from risk factors for deep infection. However, because of the limitations of the study, the authors cannot conclude that there is no effect of antibiotic implant irrigation. There is a need for a randomized, placebo-controlled trial to investigate the effect, and potential side-effects, of antibiotic implant irrigation., Clinical Question/level of Evidence: Risk, II., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Maintaining venous access is of great clinical importance. Running a slow continuous infusion to keep the vein open (KVO) is often used in peripheral intravenous catheters (PIVCs). Previous studies have compared the effects of intermittent flushing and continuous infusion via peripherally inserted central catheters (PICCs). In this study, we applied KVO to central venous catheters (CVCs) and compared the occlusion rate of this technique with that of the intermittent flushing technique., Method: This is a randomized controlled trial of 14 hospitals in China. A total of 250 patients will be recruited in this study, and they will be randomized at a 1:1 ratio. After study inclusion, patients who will undergo CVC insertion will receive intermittent flushing with prefilled saline syringes (control group) or KVO infusion with elastic pumps (test group). All the catheters will be checked for patency by scoping Catheter Injection and Aspiration (CINAS) Classification on Days 3 and 7. The primary outcome is the rate of catheter occlusion in 7 days. Patients will be followed up until 9 days after CVC insertion, catheter occlusion, or catheter removal. The secondary outcomes are the rate of catheter occlusion in 3 days, nurse satisfaction, cost-effectiveness, adverse event rate, catheter-related bloodstream infection rate, catheter-related thrombosis rate, extravasation rate, phlebitis rate, and catheter migration., Discussion: We expect that the trial will generate findings that can provide an evidence-based basis for the improvement and optimization of clinical catheter flushing techniques., Trial Registration: Chinese Clinical Trial Registry, ChiCTR2200064007. Registered on 23 September 2022. https://www.chictr.org.cn/showproj.html?proj=177311 ., (© 2024. The Author(s).)

We present the case of a child impaled in the face by a meat thermometer who subsequently suffered a significant complication due to the administration of hydrogen peroxide to the wound. The soft tissues of the face rapidly expanded and blanched, the child experienced mental status changes, and imaging revealed massive subcutaneous emphysema, pneumomediastinum, and pneumo-orbit. Herein we review the literature on this rare complication and provide photodocumentation in the hopes that other practitioners, patients, and parents avoid administering hydrogen peroxide into or near any penetrating injury. Laryngoscope, 134:2954-2957, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Background:  Neonatal intraventricular hemorrhage (IVH) may evolve into posthemorrhagic hydrocephalus and cause neurodevelopmental impairment, becoming a common complication of premature infants, occurring in up to 40% of preterm infants weighing less than 1,500 g at birth. Around 10 to 15% of preterm infants develop severe (grades III-IV) IVH. These infants are at high risk of developing posthemorrhagic hydrocephalus. Neuroendoscopic lavage (NEL) is a suitable alternative for the management of this pathology. In this study, an endoscopic surgical approach directed toward the removal of intraventricular hematoma was evaluated for its safety and efficacy., Methods:  Between August 2016 and December 2019 (29 months), 14 neonates with posthemorrhagic hydrocephalus underwent NEL for removal of intraventricular blood by a single senior neurosurgeon. Complications such as reintervention and ventriculoperitoneal (VP) shunt placement were evaluated prospectively with an 18-month follow-up on average., Results:  In total, 14 neonates with IVH grades III and IV were prospectively recruited. Of these, six neonates did not need a VP shunt in the follow-up after neuroendoscopy (group 1), whereas eight neonates underwent a VP shunt placement (group 2). Nonsignificant difference between the groups was found concerning days after neuroendoscopy, clot extraction, third ventriculostomy, lamina terminalis fenestration, and septum pellucidum fenestration. In group 2, there was shunt dysfunction in five cases with shunt replacement in four cases., Conclusion:  NEL is a feasible technique to remove intraventricular blood degradation products and residual hematoma in neonates suffering from posthemorrhagic hydrocephalus. In our series, endoscopic third ventriculostomy (ETV) + NEL could be effective in avoiding hydrocephalus after hemorrhage (no control group studied). Furthermore, patients without the necessity of VP-shunt had a better GMFCS in comparison with shunted patients., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: Fat embolism (FE) following intramedullary (IM) reaming can cause severe pulmonary complications and sudden death. Recently, a new harvesting concept was introduced in which a novel aspirator is used first for bone marrow (BM) aspiration and then for subsequent aspiration of morselized endosteal bone during sequential reaming (A + R + A). In contrast to the established Reamer-Irrigator-Aspirator (RIA) 2 system, the new A + R + A concept allows for the evacuation of fatty BM prior to reaming. In this study, we hypothesized that the risk of FE, associated coagulopathic reactions and pulmonary FE would be comparable between the RIA 2 system and the A + R + A concept., Materials and Methods: Intramedullary bone graft was harvested from intact femora of 16 Merino sheep (age: 1-2 years) with either the RIA 2 system (n = 8) or the A + R + A concept (n = 8). Fat intravasation was monitored with the Gurd test, coagulopathic response with D-dimer blood level concentration and pulmonary FE with histological evaluation of the lungs., Results: The total number and average size of intravasated fat particles was similar between groups (p = 0.13 and p = 0.98, respectively). D-dimer concentration did not significantly increase within 4 h after completion of surgery (RIA 2: p = 0.82; A + R + A: p = 0.23), with an interaction effect similar between groups (p = 0.65). The average lung area covered with fat globules was similar between groups (p = 0.17)., Conclusions: The use of the RIA 2 system and the novel A + R + A harvesting concept which consists of BM evacuation followed by sequential IM reaming and aspiration of endosteal bone, resulted in only minor fat intravasation, coagulopathic reactions and pulmonary FE, with no significant differences between the groups. Our results, therefore, suggest that both the RIA 2 system and the new A + R + A concept are comparable technologies in terms of FE-related complications., (© 2024. The Author(s).)

Objective: To explore the clinical efficacy of posterior femoral muscle flaps combined with posterior femoral cutaneous nerve nutrient vessel flap and closed lavage in the treatment of stage Ⅳ ischial tuberosity pressure ulcers. Methods: This study was a retrospective observational study. From March 2021 to March 2022, 15 patients with stage Ⅳ ischial tuberosity pressure ulcers who met the inclusion criteria were admitted to Dezhou Dongcheng Hospital, including 11 males and 4 females, aged 31 to 72 years. The pressure ulcer wound size ranged from 6.0 cm×4.5 cm to 10.0 cm×6.0 cm, with cavity diameters of 10-14 cm. Five cases were complicated with ischial tuberosity bone infection. After clearing the lesion, the biceps femoris long head muscle flap with an area of 10.0 cm×4.0 cm-18.0 cm×5.0 cm and the semitendinosus muscle flap with an area of 8.0 cm×4.0 cm-15.0 cm×5.0 cm combined with the posterior femoral cutaneous nerve nutrient vessel flap with an area of 6.5 cm×5.5 cm-10.5 cm×6.5 cm was transplanted to repair the pressure ulcer wound. The flap donor area was directly sutured, and the closed lavage with tubes inserted into the wound cavity was performed for 2-3 weeks. The postoperative survival of the muscle flaps and skin flaps, the wound healing of the donor and recipient areas were observed. The recurrence of pressure ulcers, the appearance and texture of flaps, and scar conditions of the donor and recipient areas were followed up. Results: All the muscle flaps and skin flaps in the 15 patients successfully survived after surgery. Two patients experienced incisional dehiscence at one week after surgery due to improper turning over, during which the incision in the recipient area was pressed on, and the wounds healed after dressing changes of 3 to 4 weeks; the wounds in the donor and recipient areas healed well in the other patients. All patients received follow-up after surgery. During the follow-up period of 6 to 12 months, none of the patients experienced pressure ulcer recurrence, and the texture, color, and thickness of the skin flaps closely resembled those of the surrounding skin at the recipient site, with only linear scar left in the donor and recipient areas. Conclusions: When using the posterior femoral muscle flaps combined with the posterior femoral cutaneous nerve nutrient vessel flap and closed lavage to treat stage Ⅳ ischial tuberosity pressure ulcers, the tissue flap can be used to fully fill in the dead space of the pressure ulcers. After treatment, the wound heals well, the appearance of the donor and recipient areas is better, and the pressure ulcers are less prone to reoccur.

Background: The development of endoscopic systems that include bipolar electrocautery has enabled the use of normal saline irrigation in transurethral or transcervical endoscopic surgery. However, excessive saline absorption can cause hyperchloremic metabolic acidosis., Case Presentation: Patient 1: A 76-year-old man was scheduled for transurethral resection of the prostate with saline irrigation. Approximately 140 min after the surgery, abdominal distension and cervical edema were observed. Abdominal ultrasound examination indicated a subhepatic hypoechoic lesion, which suggested extravasation of saline. Arterial blood gas analysis revealed hyperchloremic metabolic acidosis. The patient was extubated 2 h after the operation with no subsequent airway problems, and the electrolyte imbalance was gradually corrected. Patient 2: A 43-year-old woman was scheduled for transcervical resection of a uterine fibroid with saline irrigation. When the drape was removed after the operation was finished, notable upper extremity edema was observed. Arterial blood gas analysis revealed hyperchloremic metabolic acidosis. The patient's acidemia, electrolyte imbalance, and neck edema gradually resolved, and the patient was extubated 16 h after the operation without subsequent airway problems., Conclusions: Anesthesiologists should be aware of acidemia, cardiopulmonary complications, and airway obstruction caused by excessive saline absorption after saline irrigation in endoscopic surgery., (© 2024. The Author(s).)

Introduction: Pulsed lavage irrigation (PLI) is a procedure used to wash contaminated soft tissues and prevent infection in orthopedic surgery. We applicated PLI for surgical treatment of infective endocarditis( IE)., Subjects and Methods: From January 2017 to June 2021, 6 cases underwent surgical treatment IE using PLI. We investigated an efficacy of PLI., Results: Infected valves were mitral valve in 4 cases, aortic valve in 1 case, and aortic prosthetic valve in 1 case. The performed procedures were mitral valve plasty in 4 cases, aortic valve replacement in 1 case, and 1 removal of vegetation on the aortic prosthetic valve. No recurrence of IE or no deterioration of the native valve or the prosthetic valve was observed in follow-up periods., Conclusion: PLI was useful for surgical treatment of IE because of no recurrence of IE or no deterioration of native mitral valves or the aortic prosthetic valve.

Aims: Failure of radiofrequency (RF) ablation of ventricular arrhythmias is often due to inadequate lesion size. Irrigated RF ablation with half-normal saline (HNS) has the potential to increase lesion size and reduce sodium delivery to the patient if the same volume of RF irrigant were used for normal saline (NS) and HNS but could increase risks related to steam pops and lesion size. This study aims to assess periprocedural complications and acute ablation outcome of ventricular arrhythmias ablation with HNS., Methods and Results: Prospective assessment of outcomes was performed in 1024 endocardial and/or epicardial RF ablation procedures in 935 consecutive patients (median age 64 years, 71.2% men, 73.4% cardiomyopathy, 47.2% sustained ventricular tachycardia). Half-normal saline was selected at the discretion of the treating physician. Radiofrequency ablation power was generally titrated to a ≤15 Ω impedance fall with intracardiac echocardiography monitoring. Half-normal saline was used in 900 (87.9%) and NS in 124 (12.1%) procedures. Any adverse event within 30 days occurred in 13.0% of patients treated with HNS RF ablation including 4 (0.4%) strokes/transient ischaemic attacks and 34 (3.8%) pericardial effusions requiring treatment (mostly related to epicardial access). Two steam pops with perforation required surgical repair (0.2%). Patients who received NS irrigation had less severe disease and arrhythmias. In multivariable models, adverse events and acute success of the procedure were not related to the type of irrigation., Conclusion: Half-normal saline irrigation RF ablation with power guided by impedance fall and intracardiac echocardiography has an acceptable rate of complications and acute ablation success while administering half of the saline load expected for NS irrigation., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Focus on reviewing a vigorous research effort to improve the safety profile of vancomycin powder (VP) and its optimal dose in reducing periprosthetic joint infection (PJI) is the need of the hour. This systematic review and meta-analysis attempt to explore the ongoing use of VP and VP + povidone iodine (PI) lavage to prevent PJI of hip/knee arthroplasties and highlights its challenges among the orthopedic community about the existence of the major organism and its frequency in total joint arthroplasty (TJA) patients., Methods: We searched PubMed/MEDLINE, EMBASE databases regarding the outcomes of vancomycin powder (VP) and VP + povidone iodine (PI) combination in preventing periprosthetic joint infection of hip and knee arthroplasties., Results: In 5 of 7 studies, the combination of vancomycin powder (VP) and povidone iodine (PI) lavage have shown a lower risk of periprosthetic joint infection (PJI) in acute and high-risk hip and knee arthroplasties patients, with less or without serious adverse events and readmissions; while four of seven studies using VP-only found increasing rates of PJI in primary total knee arthroplasty and partial hip replacement in elderly patients with comorbidities, and significantly causes aseptic wound complications compared to the control group., Conclusions: Intra-articular vancomycin powder (VP) and povidone iodine (PI) lavage showed a significant reduction of periprosthetic joint infection in primary and revision total joint arthroplasty. Before its widespread use in clinical settings, prospective randomized studies and, most importantly, its long-term efficacy and safety are recommended., Competing Interests: Declaration of competing interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2022 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Although long-term stent placement via endoscopic gallbladder stenting (EGBS) reportedly reduces cholecystitis recurrence in patients unfit to undergo cholecystectomy, it can increase the frequency of other late adverse events (AEs) such as cholangitis. This study aimed to examine the feasibility of endoscopic gallbladder inside-stenting (EGB-IS) with lavage and aspiration. This prospective, single-center, pilot study enrolled 83 patients with acute calculous cholecystitis who were poor candidates for surgery. A dedicated catheter with eight side holes was used for lavage and aspiration, and a dedicated single-pigtail stent equipped with a thread was used for EGB-IS. Outcomes such as technical success, clinical success, early AEs, recurrence of cholecystitis, and other symptomatic late AEs associated with EGB-IS with lavage and aspiration were evaluated. The technical and clinical success rates were 80.7% (67/83) and 98.5% (66/67), respectively. The rate of early AEs was 3.6% (3/83). The rate of recurrent cholecystitis was 4.5% (3/66) and that of symptomatic late AEs (besides cholecystitis) was 6.1% (4/66). Consequently, the rate of overall late AEs (cholecystitis plus other events) was 10.6% (7/66). The 1-, 2-, and 3-year cumulative incidence rates of all late AEs were 3.2%, 11.2%, and 18.9%, respectively. EGB-IS with lavage and aspiration for calculous cholecystitis showed promising results in poor surgical candidates. EGB-IS may be useful when EGBS with long-term stent placement is planned, since prevention of cholecystitis recurrence, without a rise in the incidence of other AEs, is anticipated., (© 2023. The Author(s).)

Background: This study aims to investigate the outcomes of patients who received early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophagectomy due to esophageal cancer., Methods: A prospective randomized clinical trial was performed between March 2020 and June 2022. Patients who were scheduled for thoracoscopic and laparoscopic esophagectomy due to esophageal cancer were enrolled. Then, these patients were assigned to the control group (traditional postoperative care) and study group (traditional postoperative care with early bronchoscopic sputum aspiration and lavage). The outcomes, which included the length of hospital stay and medical expenses, and postoperative complications, which included pulmonary infection, atelectasis, respiratory dysfunction and anastomotic leakage, were compared between these two groups., Results: A total of 106 patients were enrolled for the present study, and 53 patients were assigned for the control and study groups. There were no statistically significant differences in gender, age, and location of the esophageal cancer between the two groups. Furthermore, the length of hospital stay was statistically significantly shorter and the medical expenses were lower during hospitalization in the study group, when compared to the control group (12.3 ± 1.2 vs. 18.8 ± 1.3 days, 5.5 ± 0.9 vs. 7.2 ± 1.2 Chinese Yuan, respectively; all, P < 0.05). Moreover, there were statistically significantly fewer incidences of overall complications in study group, when compared to the control group (20.7% vs.45.2%, P < 0.05)., Conclusions: For patients with esophageal cancer, early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophagectomy can shorten the length of hospital stay, and lower the medical expense and incidence of postoperative complications., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Study Objective: Cerebrospinal fluid (CSF) drainage and lavage are reported to reduce drug exposure after inadvertant intrathecal drug administration errors. This reviews aims to provide recommendations for this salvage technique, with regard to methodology, effectiveness and adverse events., Design: Systematic review. A search in the databases of Embase, Medline, Web of Science, Cochrane Central Register of Randomized Trials and Google Scholar was performed in 2022., Study Eligibility Criteria: All reports of individual patient data with CSF drainage or lavage with a percutaneous lumbar access for an intrathecal drug error were included., Measurements: The primary outcome is the description and count of CSF drainage or lavage, such as times and volume of drainage, volume of replacement and type of replacement fluid. Secondary outcomes are the effects, adverse events and overall outcome., Main Results: 58 cases were found, of which 24 were paediatric cases. There was a large variance in methodology, with regard to volume t and type of replacement fluid. In 45% of the cases the intrathecal drug removal continued. The effects were specifically reported in 27 cases, all demonstrated drug removal based on drug concentrations in the CSF (n = 20) and clinical signs (n = 7). Adverse effects were sought for in 17 cases and found intracranial haemorrhage in 3 cases. No interventions were required for these adverse events and the only reported long-term sequelae in these three patients was short-term memory impairment up to 6 months after the event (n = 1). The overall outcome depended largely on the causative agent., Conclusions: This review shows that CSF drainage or lavage leads to intrathecal drug removal, but it is unsure if this intervention leads to improved overall patient outcome. Based on aggregated data from case reports, we provide recommendations that may guide clinicians. The risk-benefit ratio should be weighed on a case-to-case basis., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: A hyperosmolar ascorbic acid-enriched polyethylene glycol-electrolyte (ASC-PEG) lavage solution ensures excellent bowel preparation before colonoscopy; however, no study has demonstrated the efficacy of this lavage solution before surgery. This study aimed to establish the non-inferiority of ASC-PEG to the standard polyethylene glycol-electrolyte solution (PEG-ELS) in patients undergoing laparoscopic resection for colorectal cancer., Methods: This was a prospective, single-blind, multicenter, randomized, controlled, non-inferiority clinical trial. Overall, 188 patients scheduled for laparoscopic colorectal resection for single colorectal adenocarcinomas were randomly assigned to undergo preparation with different PEG solutions between August 2017 and April 2020 at four hospitals in Japan. Participants received ASC-PEG (Group A) or PEG-ELS (Group B) preoperatively. The primary endpoint was the ratio of successful bowel preparations using the modified Aronchick scale, defined as "excellent" or "good.", Results: After exclusion, 86 and 87 patients in Groups A and B, respectively, completed the study, and their data were analyzed. ASC-PEG was not inferior to PEG-ELS in terms of effective bowel preparation prior to laparoscopic colorectal resection (0.93 vs. 0.92; 95% confidence interval, - 0.078 to 0.099, p = 0.007). The total volume of cleansing solution intake was lower in Group A than in Group B (1757.0 vs. 1970.1 mL). Two and three severe postoperative adverse events occurred in Groups A and B, respectively. Patient tolerance of the two solutions was almost equal., Conclusions: ASC-PEG is effective for preoperative bowel preparation in patients undergoing laparoscopic resection for colorectal cancer and is non-inferior to PEG-ELS., (© 2023. Japanese Society of Gastroenterology.)

This systematic review investigates whether different irrigation techniques have different effects on irrigant extrusion from mature tooth apices. Articles published between January 2000 and January 2022 were searched in six electronic databases (MEDLINE, Embase, Google Scholar, Web of Science, Scopus and Cochrane) using appropriate keywords. Overall, 2265 articles were screened by their titles and abstracts. Fifty-six full-text articles were selected based on the inclusion criteria. Of them, 17 in vitro studies were included in the systematic review and meta-analysis. The meta-analysis was conducted using the random-effects inverse variance method. The results showed that the negative pressure technique caused a lesser amount (p = 0.00) and frequency (p = 0.00) of extrusion than the open-ended needle irrigation. Sonic and ultrasonic activation caused less amount of extrusion than both open-ended (p = 0.00 or p = 0.01) and closed-ended needle (p = 0.00) irrigation., (© 2022 Australian Society of Endodontology Inc.)

To maintain visualization and control temperature elevation during ureteroscopy, higher irrigation rates are necessary, but this can increase intrarenal pressure (IRP) and lead to adverse effects like sepsis. The IRP is also dependent on outflow resistance but this has not been quantitatively evaluated in a biological system. In this study, we sought to characterize the IRP as a function of irrigation rate in an in vivo porcine model at different outflow resistances. Ureteroscopy was performed in a porcine model with a 9.5 Fr prototype ureteroscope containing a pressure sensor. A modified ureteral access sheath (UAS) (11/13 Fr, 36 cm) was configured to adjust outflow resistance. IRP-irrigation rate curves were generated at four different outlet resistances representing different outflow scenarios. At lower irrigation rates, the pressure change in response to increased irrigation was gradual and non-linear, likely reflecting a "compliant" phase of the renal collecting system. Once IRP reached the range of 35-50 cm H 2 O, the pressure increased in a linear fashion with irrigation rate, suggesting that the distensibility of the collecting system had become saturated. The relationship between IRP and irrigation rate becomes linear during in vivo porcine studies once the initial compliance of the system is saturated. IRP is more sensitive to changes in irrigation rate in systems with higher outflow resistance. The modified UAS is a novel research tool which allows variance of outflow resistance to mimic different clinical scenarios. Knowledge of outflow resistance may simplify the decision to use an UAS., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: Complications associated with the application of the Reamer-irrigator-Aspirator (RIA) system are described in the literature. However, to date a systematic review and meta-analysis to assess prevalence of complications associated with the use of the RIA system have not been conducted., Materials and Methods: The review is registered with PROSPERO (CRD42021269982). MEDLINE, the Web of Science Core Collection, and Embase were searched from the inception to 10 August 2021. The primary objective was to assess complications and blood loss associated with the use of the RIA system., Results: Forty-seven studies involving 1834 procedures performed with the RIA system were finally included. A total of 105 complications were reported, with a pooled estimated overall prevalence of 1.7% with a 95% confidence interval (CI) of 0.40 to 3.60, with cortex perforation being the largest reported complication with a total of 34 incidences. A significant subgroup difference was observed (p = 0.02). In subgroup 1 (bone graft harvesting), complication prevalence was 1.4% (95% CI 0.2-3.4); in subgroup 2 (clearance intramedullary canal) it was 0.7% (95% CI 0.00-6.30) and in subgroup 3 (reaming with RIA system prior to nail fixation) 11.9% (95% CI 1.80-26.40). No statistically significant difference for tibia and femur as RIA system application site was observed (CI 0.69-4.19). In studies reporting blood loss, a mean volume of 803.29 ml, a mean drop of hemoglobin of 3.74 g/dl and a necessity of blood transfusion in 9.72% of the patients were observed., Conclusions: The systematic review and meta-analysis demonstrate a low overall prevalence rate of complications associated with the RIA system. However, especially the risk of cortical perforation and the frequently reported relevant intraoperative blood loss are complications that should be anticipated in perioperative management and ultimately considered when using the RIA system., (© 2022. The Author(s).)

Objective: To map available scientific evidence about the pediatric population with spina bifida submitted to transanal irrigation to manage signs and symptoms of neurogenic bowel., Source of Data: This research was developed according to recommendations from the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Reviews. Searches were carried out in the databases: CINAHL, Medline/Pubmed, Scielo, Scopus, Web of Science, Embase, LILACS, Proquest, and the CAPES catalog of theses and dissertations. Quantitative and qualitative studies on the topic were included, as long as they dealt with this population. There was no predetermined time frame., Summary of the Findings: The authors found 1.020 studies, selected 130 for close reading, and included 23 in the review, all of which had been published from 1989 to 2021. The authors mapped the characteristics of the studies, including their definitions of concepts and use of scales, criteria for the indication of transanal irrigation, training to carry out the procedure, devices and solutions used, number and frequency of transanal irrigations, health care actions, time spent, associated complications, complementary exams, adherence rate, follow-up, and outcomes, focusing on the benefits for bowel management., Conclusions: Despite the variability of evaluation parameters and term definitions, evidence suggests that transanal irrigation is a safe and effective method to manage fecal incontinence. Studies in the field are likely to grow, using standardized scales and longitudinal follow-ups. The authors suggest further research on transanal irrigation in the pediatric population with spina bifida in the Latin American context., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2023 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

Background/purpose: In hepatobiliary and pancreatic (HBP) surgery, the role and significance of intra-abdominal lavage (IAL) for surgical site infection (SSI) is controversial., Methods: This prospective study was performed between July 2020 and July 2022. A total of 150 patients, 10-L IAL was performed. The lavage fluid at 1-L, 5-L, and 10-L was subjected to bacterial culture examination. Risk factors for SSI were evaluated., Results: Bacterial positivity rate significantly decreased as follows: 1-L, 36% (n = 54); 5-L, 27% (n = 41); 10-L, 23% (n = 35) (36% vs 23%, p = .001). Patients with positive lavage fluid culture at 10-L had significantly higher incidence of both incisional (37% vs 6%, p < .01) and organ/space (54% vs 3%, p < .01) SSI. Multivariate analysis revealed positivity for bacterial culture at 10-L as the strongest independent risk factor for incisional SSI (OR 13.0, 95% CI: 3.86-43.6, p < .01), followed by postoperative pancreatic fistula (OR 11.7, 95% CI: 3.03-45.6, p < .01). Likewise, in organ/space SSI, positivity for bacterial culture at 10-L was the strongest independent risk factor (OR 48.9, 95% CI:12.1-197.7, p < .01), followed by digestive reconstruction (OR 5.20, 95% CI: 1.45-18.6, p = .01)., Conclusion: IAL decreased the intraperitoneal contamination rate in a volume-dependent manner and can be useful in the surveillance of SSI development in HBP surgery., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Objectives: Sonic/ultrasonic devices are essential tools in today's endodontics. This prospective trial evaluated for the first time the impact of practitioners' proficiency levels and patient-related factors on complications associated with a high frequency polyamide sonic irrigant activation device., Methods: In total 334 patients (females:158, males:176; age:18-95 years) received in the course of their endodontic therapy an intracanal irrigation, using a high frequency polyamide sonic irrigant activation device, by practitioners of different proficiency levels (undergraduate students, general practitioners or endodontists). Intracanal bleeding (yes/no), postoperative pain (0-10 scale), emphysema (yes/no) and polyamide tip fractures (yes/no) were recorded and related to proficiency levels, age, gender, tooth type, smoking-status, systemic conditions affecting healing ability, baseline pain, swelling, fistula, sensitivity to percussion and diagnosis., Results: Intracanal bleeding was associated with patients' age (p<0.05), baseline pain level (OR = 1.14, 95%CI = 0.91-1.22) and baseline swelling (OR = 2.73, 95%CI = 0.14-0.99; p<0.05) but not proficiency level, gender, tooth type, smoking, systemic conditions, baseline fistula or sensitivity to percussion (p>0.05). Postoperative pain development was related to proficiency level (p<0.05) and baseline pain level (p<0.001), with no influence of age, gender, tooth type, smoking, systemic conditions, baseline fistula, swelling or sensitivity to percussion (p>0.05). Emphysema and polyamide tip fractures were not reported., Conclusions: Within the current study's limitations, younger patients with higher baseline pain and swelling, were associated with higher intracanal bleeding. Apart from higher postoperative pain observed with less experienced practitioners, proficiency level had no influence on bleeding, polyamide tip fracture or emphysema, endorsing the high frequency polyamide sonic irrigation device as a safe therapeutic device., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Hahn et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background/objectives: The QDOT-MICRO™ catheter allows very high-power and short-duration (vHPSD) ablation. This study aimed to investigate lesion characteristics using different ablation settings., Methods: Radiofrequency applications (90 W/4 s, temperature-control mode with 55°C or 60°C target) were performed in excised porcine myocardium using three different approaches: single (SA), double nonrepetitive (DNRA), and double repetitive applications (DRA). Applications were performed with an interval of 1 min for DNRA, and without interval for DRA., Results: A total of 480 lesions were analyzed. Lesion depth and volume were largest for DRA followed by DNRA and SA regardless of catheter direction (depth: 3.8 vs. 3.3 vs. 2.6 mm, p < .001 for all comparisons; volume: 176.6 vs. 145.1 vs. 97.0 mm 3 , p < .001 for all comparisons). Surface area was significantly larger for DRA than for SA (45.1 vs. 38.3 mm 2 , p < .001) and larger for DNRA than for SA (44.5 vs. 38.3 mm 2 , p < .001), but was similar between DRA and DNRA (45.1 vs. 44.5 mm 2 , p = .54). Steam-pops more frequently occurred for DRA than for SA (15.6% vs. 4.4%, p = .004) and DNRA (15.6% vs. 6.9%, p = .061), but the incidence was similar between SA and DNRA (4.4% vs. 6.9%, p = 1). Although surface area and lesion volume were larger in lesions with steam-pops than without steam-pops (46.5 vs. 38.1 mm 2 , p = .018 and 128.3 vs. 96.8 mm 3 , p = .068, respectively), lesions were not deeper (pop(+): 2.5 mm vs. pop(-): 2.6 mm, p = .75)., Conclusions: DNRA produces larger lesions than SA without increasing the risk of steam-pops. DRA produces the largest lesions among the three groups, but with an increased risk of steam-pops. Even with steam-pops, lesions do not become deeper in vHPSD ablation., (© 2023 Wiley Periodicals LLC.)

Introduction: The QDOT-Micro TM catheter is a novel irrigated contact force (CF) sensing catheter which benefits from thermocouples for temperature monitoring, allowing temperature-flow-controlled (TFC) ablation. We compared lesion metrics at fixed ablation index (AI) value during TFC-ablation and conventional power-controlled (PC)-ablation., Methods: A total of 480 RF-applications were performed on ex-vivo swine myocardium with predefined AI targets (400/550) or until steam-pop occurred, using the QDOT-Micro TM (TFC-ablation) and Thermocool SmartTouch SF TM (PC-ablation)., Results: Both TFC-ablation and PC-ablation produced similar lesions in volume (218 ± 116 vs. 212 ± 107 mm 3 , p = .65); however, lesions using TFC-ablation were larger in surface area (41.3 ± 8.8 vs. 34.8 ± 8.0  mm 2 , p < .001) and shallower in depth (4.0 ± 1.0 vs. 4.2 ± 1.1 mm, p = .044). Average power tended to be lower in TFC-alation (34.2 ± 8.6 vs. 36.9 ± 9.2, p = .005) compared to PC-ablation due to automatic regulation of temperature and irrigation-flow. Although steam-pops were less frequent in TFC-ablation (24% vs. 15%, p = .021), they were particularly observed in low-CF (10 g) and high-power ablation (50 W) in both PC-ablation (n = 24/240, 10.0%) and TFC-ablation (n = 23/240, 9.6%). Multivariate analysis revealed that high-power, low-CF, long application time, perpendicular catheter orientation, and PC-ablation were risk factors for steam-pops. Furthermore, activation of automatic regulation of temperature and irrigation-flow was independently associated with high-CF and long application time while ablation power had no significant relationship., Conclusions: With a fixed target AI, TFC-ablation reduced the risk of steam-pops, producing similar lesions in volume, but with different metrics in this ex-vivo study. However, lower CF and higher power in fixed-AI ablation may increase the risk of steam-pops., (© 2023 Wiley Periodicals LLC.)

Introduction: Gram-negative rod (GNR) bacterial ventriculitis is a rare complication of shunt-dependent hydrocephalus, often requiring an extended and invasive treatment course. Accumulation of purulent material, as well as empyema and septation formation, limits circulation of antibiotics and infection clearance. Supplementation of standard care with neuroendoscopic-guided intraventricular lavage with lactated Ringer solution and fenestration of septations may facilitate infection clearance and simplify the eventual shunt construct required. Here, the utility of serial lavage for ventriculitis is described in a population of shunt-dependent neonates and infants at high risk for morbidity and mortality., Methods: Five infants with shunt-dependent hydrocephalus and subsequent GNR ventriculitis were treated with standard care measures with the addition of serial neuroendoscopic lavage. A retrospective chart review was performed to collect patient characteristics, shunt dependency, and shunt revisions within a year of ventriculitis resolution., Results: Patients demonstrated a mean 74% decrease in cerebrospinal fluid (CSF) protein following each neuroendoscopic lavage and trended toward a shorter time to infection clearance in comparison to previously published literature. Patients required 0-2 shunt revisions at 1-year follow-up following hospitalization for shunt-related ventriculitis (mean 0.8 +/- 0.8)., Conclusions: Serial neuroendoscopic lavage is an effective technique, used alone or in combination with fenestration of septations, to reduce the CSF protein and bacterial load in the treatment of ventriculitis, decreasing time until eradication of infection. Serial lavage may reduce the risk of future shunt malfunction, simplify the future shunt construct, and decrease duration of infection., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Background: Prevention of surgical site infection (SSI) after gastrectomy has received increasing attention. Prophylactic incisional wound irrigation has been advocated to reduce SSI, but the choice of solution remains under debate., Aims: To compare the efficacies of wound irrigation with normal saline (NS) and povidone-iodine (PVI) for the prevention of SSI after gastrectomy, and to identify the risk factors for SSI., Methods: This randomized, single-centre clinical trial included 340 patients with gastric cancer. They were assigned at random into two groups (ratio 1:1) to receive either 0.9% NS or 1.0% PVI solution for incisional irrigation before wound closure. The primary endpoint was postoperative SSI within 30 days of gastrectomy, and the secondary endpoint was the length of hospital stay., Findings: In total, 333 patients were included in the modified intent-to-treat group, and the SSI rate did not differ significantly between the PVI group (11/167, 6.59%) and the NS group (9/166, 5.42%) [odds ratio (OR) 1.131, 95% confidence interval (CI) 0.459-3.712; P=0.655]. Moreover, the difference between the two groups in terms of length of hospital stay was not significant (P=0.301). Body mass index (BMI) (OR 2.639, 95% CI 1.040-6.694; P=0.041) and postoperative complications (OR 2.565, 95% CI 1.023-6.431; P=0.045) were identified as independent risk factors for SSI., Conclusions: NS and PVI had similar efficacy as prophylactic wound irrigation for the prevention of SSI after gastrectomy. The risk of SSI was higher in patients with high BMI or postoperative complications., (Copyright © 2022. Published by Elsevier Ltd.)

Background: In the treatment of native knee bacterial septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival, complications, and resource utilization between these approaches., Methods: The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D), if any, were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression., Results: A total of 14,365 patients with native knee septic arthritis undergoing I&D were identified, 8,063 arthroscopic (56.1%) and 6,302 open (43.9%). The mean follow-up was 148 days (interquartile range 53 to 259). A total of 2,156 patients (15.0%) underwent revision I&D. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $5,674 and length of stay of 1.46 days (P < 0.001 for both). Arthroscopic I&D was associated with lower overall complications (odds ratio [OR] 0.63, P < 0.001), need for blood transfusion (OR 0.58, P < 0.001), and wound complications (OR 0.32, P < 0.001). Revision-free survival after index I&D was 95.3% at 3 days, 91.0% at 10 days, 88.3% at 30 days, 86.0% at 90 days, and 84.5% at 180 days. No statistically significant difference was observed between surgical approaches on Cox modeling., Discussion: Risk of revision I&D did not differ between arthroscopic and open I&D; however, arthroscopy was associated with decreased costs, length of stay, and complications. Additional study is necessary to confirm these findings and characterize which patients require an open I&D., Level of Evidence: III., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Purpose: To evaluate the complications of arthroscopic lysis and lavage with joint sweep (ALL) procedure in the management of disc derangement of the temporomandibular joint., Methods: Patients with internal derangement of the TMJ who were treated by ALL in a tertiary institution from July 2018 to December 2021 were studied retrospectively., Results: The study included 39 patients (males, n = 14; females, n = 25) and 50 joints. The complications observed in the study were classified into intra and post operative complications. Post operative complications such as pain (16%), swelling (6%), reduced mouth opening (22%) and neurological complications were the most commonly observed ones. Rare complications such as ipsilateral palatal swelling (6%), parapharyngeal swelling (4%), and post operative malocclusion (2%) were also observed., Conclusion: Although the complications of ALL are entirely unavoidable, their incidence can be reduced by strict adherence to standard techniques. Three-dimensional awareness and orientation of the dangerous angles and depth around the TMJ region is mandatory to reduce the complications., Competing Interests: Declaration of Competing Interest The authors declare they have no competing interests in publication of this manuscript., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Painful eye conditions are a therapeutic challenge in horses. Subpalpebral lavage (SPL) treatment systems allow topical aqueous medications to be conveniently, safely, and frequently administered to the ocular surface. The aim of this retrospective study was to describe the outcomes and the complications associated with the location of the SPL treatment systems, in the superior or inferior eyelid in horses in a university practice. Clinical records of all horses admitted to the National Veterinary School of Alfort between January 2004 and October 2021, in which a SPL treatment system was used to administer the topical ophthalmic medications, were reviewed. Sixty horses were included in the study representing 61 SPL treatment systems. Uneventful outcomes occurred in 53 cases (86.9%) and complications were recorded in 8 cases (13.1%). Seven complications were reported for upper eyelid systems (23.3%) and 1 complication for lower eyelid systems (4.2%). The complication rates were not significantly different between these two locations (P= .06). The complications identified were iatrogenic corneal ulceration, palpebral abscess, overgrowth of conjunctiva over the footplate, and palpebral cellulitis. Median duration of SPL treatment system use was 7.5 days. The easier placement and removal and the lower incidence of complications identified in our study encourage the authors to favor the lower fornix for subpalpebral lavage treatment systems within our equine hospital., (Copyright © 2022. Published by Elsevier Inc.)

Deep sternal wound infection (DSWI) with prosthetic graft infection is a rare, though lethal, complication after cardiovascular surgery via median sternotomy. This commentary is a review of a report by Takagi et al. published in the Journal of Cardiac Surgery that reported favorable outcomes in patients with DWSI with prosthetic graft infection treated with an enhanced strategy consisting of hydrodebridement with pulsed lavage and negative pressure wound therapies., (© 2022 Wiley Periodicals LLC.)

Background: The greater likelihood of morbidity, mortality, length of hospital stays and poorer long-term outcomes as a result of surgical site infections secondary to spinal surgery makes prophylactic measures an imperative focus. Therefore, the aim of this review was to evaluate the available research related to the efficacy of different intraoperative irrigation techniques used in spinal surgery for surgical site infection (SSI) prophylaxis., Methods: We performed a comprehensive search using Ovid Medline, EMBASE, Web of Science and the Cochrane library pertaining to this topic. Our meta-analysis was conducted according to PRISMA guidelines. The inclusion criteria consist of spine surgeries with intraoperative use of any wound irrigation technique, comparison groups with a different intraoperative irrigation technique or no irrigation, SSI identified with bacterial cultures or clinically in the postoperative period, reported SSI rates. Data extracted from eligible studies included, but was not limited to, SSI rates, irrigation technique and control technique. Exclusion criteria consist of articles with no human subjects, reviews, meta-analyses and case control studies and no details about SSI identification or rates. Pooled risk ratios were calculated. A meta-analysis was performed with a forest plot to determine risk estimates' heterogeneity with I 2 index, Q-statistic, and p value under a random-effects model. Funnel plot was used to assess publication bias. All databases were last checked on January, 2022. PROBAST tool was used to assess both risk of bias and applicability concerns., Results: After reviewing 1494 titles and abstracts, 18 articles met inclusion criteria. They included three prospective randomized-controlled trials, 13 retrospective cohort studies, two prospective cohort studies. There were 54 (1.8%) cases of SSIs in the povidone-iodine irrigation group (N = 2944) compared to 159 (4.6%) in the control group (N = 3408). Using intraoperative povidone-iodine wound irrigation produced an absolute risk reduction of 2.8%. Overall risk ratio was 0.32 (95% CI 0.20-0.53, p < 0.00001). In a global analysis, study heterogeneity and synthesizing mostly retrospective data were primary limitations., Conclusion: The most evidence exists for povidone-iodine and has Level 2 evidence supporting SSI reduction during spinal surgery. Other antiseptic solutions such as dilute chlorhexidine lack published evidence in this patient population which limits the ability to draw conclusions related to its use in spinal surgery., Level of Evidence: II - Systematic Review with Meta-Analysis., (© 2022. The Author(s).)

Cases of empyema associated with Histoplasma infection are rarely reported. Here, we discuss a case of Histoplasma -associated empyema successfully treated with amphotericin B intravenous and pleural infusion therapy and multiple medical thoracoscopies. A 57-year-old Chinese woman with preexisting diabetes mellitus and gastric cancer had massive left-sided pleural effusion diagnosed by chest computed tomography. Her pleural effusion was purulent through pleural catheter drainage, and the culture of the pleural fluid showed Escherichia coli and Streptococcus constellation. Histopathology of the thoracoscopic pleural biopsy after hexamine silver and PAS staining supported Histoplasma infection. The patient was treated with intravenous injection and local thoracic irrigation of amphotericin B and continuous oral administration of itraconazole. At the same time, the patient received thoracic cannulation, daily thoracic lavage and thoracoscopy for purulent and necrotic tissue removal three times during hospitalization. The patient's pleural effusion and necrotic tissue in the pleural cavity were significantly reduced in a short time, and the clinical symptoms were significantly improved. After discharge, the patient recovered well and had no obvious complications or sequelae. Intravenous injection and local thoracic irrigation of amphotericin B are safe and effective drug therapies to treat fungal-associated empyema such as Histoplasma . Medical thoracoscopy effectively shortens the recovery time of empyema, improving the prognosis and reducing complications., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Cui, Wang and Zhao.)

Standard initial treatment for acute empyema involves antibiotic administration and chest tube drainage; however, pleural lavage with saline is another treatment that mitigates the need for surgical drainage. Although this treatment is recognised as non-invasive and safe, the complications of cerebral air embolism are less recognised.In this case, a man in his late 40s was diagnosed with acute empyema and treated with chest tube (28 Fr) drainage and antibiotics. Empyema remained on follow-up chest imaging; thus intrapleural fibrinolytic therapy (urokinase 120 000 units/day for a total of 3 days) and pleural lavage (0.9% saline 1000 mL/day daily) were administered. During the 10th pleural lavage, the patient suddenly became unconscious. Head imaging revealed a cerebral air embolism. Consequently, he received urgent hyperbaric oxygen therapy and improved without any neurological sequelae.Clinicians should be aware of the complications of sudden cerebral air embolism due to pleural lavage for empyema., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: During radiofrequency ablation (RFA) using conventional RFA catheters (RFC), ~90% of the energy dissipates into the bloodstream/surrounding tissue. We hypothesized that a novel insulated-tip ablation catheter (SMT) capable of blocking the radiofrequency path may focus most of the energy into the targeted tissue while utilizing reduced power and irrigation., Methods: This study evaluated the outcomes of RFA using SMT versus an RFC in silico, ex vivo, and in vivo. Radiofrequency applications were delivered over porcine myocardium (ex vivo) and porcine thigh muscle preparations superfused with heparinized blood (in vivo). Altogether, 274 radiofrequency applications were delivered using SMT (4-15 W, 2 or 20 ml/min) and 74 applications using RFC (30 W, 30 ml/min)., Results: RFA using SMT proved capable of directing 66.8% of the radiofrequency energy into the targeted tissue. Accordingly, low power-low irrigation RFA using SMT (8-12 W, 2 ml/min) yielded lesion sizes comparable with RFC, whereas high power-high irrigation (15 W, 20 ml/min) RFA with SMT yielded lesions larger than RFC (p < .05). Although SMT was associated with greater impedance drops ex vivo and in vivo, ablation using RFC was associated with increased charring/steam pop/tissue cavitation (p < .05). Lastly, lesions created with SMT were more homogeneous than RFC (p < .001)., Conclusion: Low power-low irrigation (8-12 W, 2 ml/min) RFA using the novel SMT ablation catheter can create more uniform, but comparable-sized lesions as RFC with reduced charring/steam pop/tissue cavitation. High power-high irrigation (15 W, 20 ml/min) RFA with SMT yields lesions larger than RFC., (© 2022 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Abstract: The purpose of this study is to evaluate the diagnosis and treatment of punctal apposition syndrome. We retrospectively reviewed the medical records of 2 patients diagnosed with punctal apposition syndrome who underwent lateral tarsal strip procedure. The patients included 1 male and 1 female, with an average age of 76.5 years. Before surgery, both patients had epiphora symptoms with a Munk score of 4 in both eyes. in the primary gaze, it was noted that the upper and lower puncta were appose with each other in both eyes throughout the blinking cycle. On slit lamp examination, there were no keratoconjunctival diseases, and the shape of the puncta were normal. On fluorescein dye disappearance test, grade 3 findings were observed in both eyes of both patients. in dacryos-cintigraphy of the 2 patients, both eyes showed complete obstruction, However, no obstruction of the lacrimal duct system was found in probing and syringing tests. The patient's subjective symptoms improved after patching test. A lateral tarsal strip procedure was performed as a treatment and we obtain satisfactory results. Therefore, punctal apposition syndrome could be 1 of the causes of epiphora., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Calcific tendinopathy of the shoulder (CTS) is the most common cause of shoulder pain. Conservative treatment is considered as the first therapeutic choice for CTS. The main objective of this study was to assess the effect of US-guided needling (UGN) compared to UGN plus Biocompatible Electrical Neurostimulation (BEN) in the treatment of the CTS. Pilot, prospective, non-interventional, monocentric, and observational study of patients treated for calcific rotator cuff tendinopathy and shoulder pain. Patients’ selection, enrollment and interventions were conducted at the Chiparo Physical Medicine and Rehabilitation outpatient facility. Forty adult patients (aged 40−60 years) with a diagnosis of CTS in the acute and colliquative phase were recruited and enrolled into the study. Participants were assessed for self-perceived pain through the Numerical Rating Scale (NRS), and for functional limitation through the Shoulder Pain and Disability Index score (SPADI) at baseline (T0), after 15 days (T1), and after 40 days (T2). As a possible confounding factor between the two treatments’ response, the dimension of the tendon calcification was also assessed by US-examination. Through the study, both groups improved their perceived functional performance of the arm (p-value < 0.001). AT T1, the SPADI score decreased by half in both groups, and the improvement remained stable at T2. A multiplicative effect (Time × Treatment) was demonstrated (p-value < 0.001). An improvement in the NRS score was measured at T1, and it remained stable at T2, a multiplicative effect was also reported (p-value < 0.001). The main results of this pilot study provide evidence that UGN plus BEN increases functional performance and reduces shoulder pain in individuals with CTS. Moreover, the tendon calcification dimension at the baseline and the percentage of drainage of the lesion were associated with a functional performance recovery and pain reduction detected after intervention.

Background: Ablation Index (AI) is a multiparametric quality marker to assess the durability of radiofrequency (RF) lesions. The comparative effectiveness and safety of AI versus time-based energy dosing for ablation of ventricular arrhythmias are unknown., Objective: We compared AI and time-based RF dosing strategies in the left ventricles (LVs) of freshly harvested porcine hearts., Methods: Ablation was performed in vitro with an open-irrigated ablation catheter (Thermocool ST/SF), 40 W, contact force 10-15 g. Tissue samples were stained in triphenyltetrazolium chloride for the measurement of lesion dimensions., Results: A total of 560 lesions were performed (AI-group: [n = 360]; time-group: [n = 200]). Using normal saline (NS) (n = 280), growth in lesion depth slowed after 30 s and AI > 550 in comparison to width, volume, and magnitude of impedance drops which continued to increase with longer RF duration. Risk of steam pop (SP) was higher for RF > 30 s (RF < 30 s:1 SP [2.5%] vs. RF > 30 s: 15 SP [25%]; p = .002) or AI targets >550 (AI: 350-550: 2 SP [2%] vs. AI 600-750: 15 SP [19%]; p = .001). Using half-normal saline (HNS) (n = 280), lesion dimension and impedance drops were larger and growth in lesion depth slowed earlier (AI: 500). Risk of SPs was higher above AI 550 (AI: 350-550: 7 [7%] SPs vs. AI 600-750: 28 [35%] SPs; p < .00001). While codependent variables, correlation between AI and time was modest-to-strong but decreased with longer RF duration., Conclusion: In this ex vivo study, AI was a better predictor of lesion dimensions than ablation time and magnitude of impedance drop in the LV using NS and HNS irrigation. AI targets above 550 led to a higher risk of SPs. Future trials are required to verify these findings., (© 2022 Wiley Periodicals LLC.)

Outcome expectations of direct pulp capping in carious teeth are obscured by a clinically unknown infiltration and breakdown of the dental pulp tissue. Histologic studies showed that this soft tissue breakdown is related to the innate immune system. We hypothesized 1) that a neutrophil biomarker could predict the outcome of direct pulp capping and 2) that using sodium hypochlorite (NaOCl) as a lavage solution to remove necrotized infected pulp tissue could improve it. In this randomized trial in mature posterior teeth causing no or mild discomfort with carious pulpal exposures, pulpal fluid was collected to assess neutrophil gelatinase (matrix metalloproteinase 9 [MMP-9]) per total protein (TP) levels as a predictive local biomarker. Subsequently, the dentin-pulp wound was randomly washed with a 2.5% NaOCl or a physiologic saline solution (1:1 allocation), capped with mineral trioxide aggregate, and the tooth was immediately restored with a resin-based composite restoration. Ninety-six patients were included, and 84 individuals could be followed up to treatment failure or clinically confirmed pulp survival after a minimum of 1 y. The entire data were fitted to a Cox proportional hazards model to assess the influence of the observational variables MMP-9/TP and discomfort with the randomized lavage treatment on pulp survival. The Kaplan-Meier pulp survival rates after 1 y were 55% for saline and 89% for NaOCl lavage. The inflammatory state of the pulp tissue as reflected by MMP-9/TP levels and NaOCl lavage had a highly significant ( P  < 0.001 and P  = 0.004, respectively) impact on pulp survival, while mild preoperative discomfort did not. In conclusion, MMP-9/TP showed great promise as a predictive local biomarker, and NaOCl lavage considerably improved the survival time of cariously exposed and directly capped pulps.

Introduction: Ablation of papillary muscles (PMs) for refractory ventricular arrhythmias can often be challenging. The catheter approach and orientation during ablation may affect optimal radiofrequency (RF) delivery. Yet, no previous study investigated the association between catheter orientation and PM lesion size. We evaluated ablation lesion characteristics with various catheter orientations relative to the PM tissue during open irrigated ablation, using a standardized, experimental setting., Methods: Viable bovine PM was positioned on a load cell in a circulating saline bath. RF ablation was performed over PM tissue at 50 W, with the open irrigated catheter positioned either perpendicular or parallel to the PM surface. Applied force was 10 g. Ablation lesions were sectioned and underwent quantitative morphometric analysis., Results: A catheter position oriented directly perpendicular to the PM tissue resulted in the largest ablation lesion volumes and depths compared with ablation with the catheter parallel to PM tissue (75.26 ± 8.40 mm 3 vs. 34.04 ± 2.91 mm 3 , p < .001) and (3.33 ± 0.18 mm vs. 2.24 ± 0.10 mm, p < .001), respectively. There were no significant differences in initial impedance, peak voltage, peak current, or overall decrease in impedance among groups. Parallel catheter orientation resulted in higher peak temperature (41.33 ± 0.28°C vs. 40.28 ± 0.24°C, p = .003), yet, there were no steam pops in either group., Conclusion: For PM ablation, catheter orientation perpendicular to the PM tissue achieves more effective and larger ablation lesions, with greater lesion depth. This may have implications for the chosen ventricular access approach, the type of catheter used, consideration for remote navigation, and steerable sheaths., (© 2022 Wiley Periodicals LLC.)

Purpose: Transurethral endoscopic procedures using bipolar current, or laser energy are nowadays widely accepted and have replaced the traditional monopolar resection. A major advantage of these techniques is the utilization of isotonic saline as irrigation solution, which minimizes side effects such as symptoms associated to classical transurethral resection syndrome (TUR-syndrome). Nonetheless, clinically significant IFA also occurs with saline and is determined by pressure gradients, systemic resistance and by the amount of irrigation fluid. We aimed to investigate the extend of IFA and symptoms due to volume overload during bipolar transurethral resection (bTUR) and laser procedures of the prostate., Methods: We performed a systematic literature search using PubMed, restricted to original English-written articles, including animal, artificial model, and human studies. Search terms were TUR, transurethral, laser, HoLEP, ThuLEP, greenlight, enucleation, fluid absorption, fluid uptake, and TUR-syndrome., Results: Mean and maximum IFA during bTURP ranges between 133 and 915 ml and 1019 ml and 2166 ml, respectively. Absorption during laser procedures can be significant with maximum values up to 4579 ml and mainly occurs during prostate vaporization techniques. Incidence of moderate to severe symptoms from iso-osmolar volume overload reaches 9%., Conclusions: Irrigation fluid absorption during bTUR and laser surgery of the prostate is not negligible. Iso-osmolar overhydration with development of non-classical TUR-syndrome should be identified peri- and postoperatively and surgical teams should be aware of complications. Breath ethanol, venous pH, serum chloride, and bicarbonate could be markers for detecting dangerous events of IFA with saline., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Currently, the same-day polyethylene glycol-electrolyte lavage solution (PEG-ELS) regimen is particularly recommended for afternoon colonoscopy as an alternative to the split-dose regimen in western countries. However, in Japan, the split-dose regimen has never been used as a standard colonoscopy preparation regimen. The aim of this study was to compare the efficacy and tolerability of split-dose PEG containing ascorbic acid (ASC) with same-day single dose PEG-ASC in Japan.This was a single-blinded, non-inferiority, two-center, randomized, controlled study. In-hospital patients were randomized to the same-day regimen or the split regimen using a web-based registry system. The same-day group was instructed to take 5 mL of sodium picosulfate in the evening, and on the day of the colonoscopy, they took 1.5 L of PEG-ASC. The split group was instructed to take 1 L of PEG-ASC before the day of colonoscopy, followed by another 1 L of PEG-ASC on the day of colonoscopy. Bowel cleansing was evaluated by the Boston Bowel Preparation Scale.A total of 153 patients were randomized to either the same-day group (n=78, males 60.0%, mean age 62.7 years) or the split group (n=75, 61.3%, 61.9 years). The rates of successful bowel cleansing were 83.3% in the same-day group vs. 92.0% (83.4%-97.0%) in the split group, P=0.10). No serious adverse events occurred in the study population. However, more patients in the same-day group were willing to repeat the same preparation regimen (P<0.001). The split-dose regimen was not inferior to the same-day regimen with respect to the efficacy of bowel preparation, but the patients preferred the same-day regimen., Competing Interests: Masahiro Tajika received honoraria from EA Pharma Co., Ltd. All other authors have no conflicts of interest to declare for this work.

A large maxillary odontogenic cyst could intrude into the maxillary sinus. The traditional approach following surgery for such a cyst is the Caldwell-Luc procedure. However, the traditional CDL procedure is associated with more complications and damage of the sinus mucosa. The purpose of this study was to assess a new method with easier operation, which not only prevented postoperative infection but also caused less damage to the maxillary sinus mucosa. A large odontogenic cyst in the maxillary sinus of 40 patients was diagnosed through radiographic imaging and postoperative histopathology. Twenty patients were treated with maxillary sinus saline irrigation after surgery, while 20 patients underwent the traditional Caldwell-Luc procedure. The therapeutic efficacy was evaluated by clinical examination and radiographic imaging; the longest follow-up was 36 months. The postoperative reaction was evaluated. There was a statistically significant difference in facial swelling, visual analog scale (VAS) and temperature elevation between the 2 groups. Sinus irrigation following large odontogenic cyst surgery involving the maxillary sinus can serve as an alternative to standard CDL and has the advantages of fewer complications, reduced trauma, restoration of the mucosa and more satisfactory results., (© 2021. The Author(s).)

The occurrence of air embolism is highly related to medical operations, and air embolism can cause sudden death. Such situations require attention in forensic work. This article reports two cases of iatrogenic air embolism confirmed by autopsy. In case 1, air embolism occurred after hydrogen peroxide was used to irrigate and disinfect a wound on the patient's left forearm. Approximately 90 ml of 3% hydrogen peroxide solution was used in case 1, and this volume can produce approximately 890 ml of oxygen by complete decomposition, which is far more than the average lethal air embolism volume. Attention should be given to the risk of air embolism when using hydrogen peroxide for irrigation and disinfection. In case 2, air embolism occurred during left ureteroscopy and stent placement. Due to inappropriate processing, the normal saline pump infused air into the patient at a high pressure of 120 mmHg. Based on our autopsy findings, we discuss the pathways of arterial air embolism and cerebral air embolism. In addition to the air entrainment volume and accumulation rate, the location of air accumulation also significantly impacts the risk of air embolism. After an arterial air embolus develops into a coronary and/or cerebral air embolus, the lethal air volume drops to only a few milliliters., (Copyright © 2021 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)