Impact of rectal perforation on recurrence during rectal cancer surgery in a national population registry.

BACKGROUND: Incidental perforation in rectal cancer surgery is considered a risk factor for poorer oncological outcome. Most studies emanate from the era before total mesorectal excision when staging, neoadjuvant treatment and surgical technique were suboptimal. This study assessed the impact of incidental perforation on oncological outcome in a cohort of patients with optimized management. METHODS: Data from the Swedish Colorectal Cancer Registry for patients undergoing R0 abdominal surgery for TNM stage I-III rectal cancer between 2007 and 2012, with 5-year follow-up, were analysed. Multivariable analysis was performed. RESULTS: In total, 6176 patients were analysed (208 with and 5968 without perforation). The local recurrence rate was increased after perforation (7·2 per cent (15 of 208) versus 3·2 per cent (188 of 5968); P = 0·001), but there were no differences in rates of distant metastasis (16·3 per cent (34 of 208) versus 19·8 per cent (1183 of 5968); P = 0·215) and overall recurrence (20·7 per cent (43 of 208) versus 21·0 per cent (1256 of 5968); P = 0·897). The 5-year overall survival rate was lower after perforation (66·4 versus 75·5 per cent; P = 0·002), but the 5-year relative survival rate was no different (79·9 versus 88·2 per cent; P = 0·083). In multivariable analysis, perforation was a risk factor for local recurrence (hazard ratio 2·10, 95 per cent c.i. 1·19 to 3·72; P = 0·011), but not for the other outcomes. CONCLUSION: Incidental perforation remains a significant risk factor for LR, even with optimized management of rectal cancer. This must be considered when discussing adjuvant treatment and follow-up.

ANTECEDENTES: La perforación incidental durante la cirugía de cáncer de recto se considera un factor de riesgo de un peor resultado oncológico. La mayoría de los estudios proceden de la era previa a la exéresis total del mesorrecto cuando la estadificación, el tratamiento neoadyuvante y la técnica quirúrgica eran subóptimos. En este estudio se evalúa el impacto de la perforación incidental en el resultado oncológico en una cohorte de pacientes con un tratamiento óptimo. MÉTODOS: Se analizaron los datos del Registro Sueco de Cáncer Colorrectal para pacientes sometidos a cirugía abdominal R0 en estadios TNM I-III entre 2007-2012 con un seguimiento de 5 años. Se realizó un análisis multivariable. RESULTADOS: En total, se analizaron 6.176 pacientes (208 con perforación, 5.968 sin perforación). La tasa de recidiva local (local recurrence, LR) aumentó después de la perforación (7,2% (15/208) versus 3,2% (188/5.968); P = 0,001)), pero no se detectaron diferencias con respecto a las tasas de metástasis a distancia (16,3% (34/208) versus 19,8% (1.183/5.968); P = 0,215)) ni de recidiva global (20,7% (43/208) versus 21,0% (1.256/5.968); P = 0,897)). La tasa de supervivencia global a los 5 años fue menor después de la perforación (66,4% versus 75,5%; P = 0,002), pero la tasa de supervivencia relativa a los 5 años fue similar (79,9% versus 88,2%; P = 0,083). En el análisis multivariable, la perforación fue un factor de riesgo para la LR (cociente de riesgos instantáneos, hazard ratio, HR 2,10 (i.c. del 95% 1,19-3,72); P = 0,011], pero no fue un factor de riesgo para los otros resultados. CONCLUSIÓN: La perforación incidental sigue siendo un factor de riesgo significativo para la LR incluso con el tratamiento optimizado del cáncer de recto, lo que debe tenerse en cuenta al discutir la indicación de tratamiento adyuvante y el tipo de seguimiento.

Standalone oblique lateral interbody fusion vs. combined with percutaneous pedicle screw in spondylolisthesis.

BACKGROUND: To compare standalone oblique lateral interbody fusion (OLIF) vs. OLIF combined with posterior bilateral percutaneous pedicle screw fixation (OLIF combined) for the treatment of lumbar spondylolisthesis. METHODS: This was a retrospective study of patients who underwent standalone OLIF or combined OLIF between 07/2014 and 08/2017 at two hospitals in China. Direct decompressions were not performed. Visual analog scale (VAS), Oswestry Disability Index (ODI), satisfaction rate, anterior/posterior disc heights (DH), foraminal height (FH), foraminal width (FW), cage subsidence, cage retropulsion, fusion rate, and complications were analyzed. All imaging examinations were read independently by two physicians and the mean measurements were used for analysis. RESULTS: A total of 73 patients were included: 32 with standalone OLIF and 41 with combined OLIF. The total complication rate was 25.0% with standalone OLIF and 26.8% with combined OLIF. There were no differences in VAS and ODI scores by 2 years of follow-up, but the scores were better with standalone OLIF at 1 week and 3 months (P < 0.05). PDH and FW was smaller in the combined OLIF group compared with the standalone OLIF group before and after surgery (all P < 0.05). There were significant differences in FH before surgery and at 1 week and 3 months between the two groups (all P < 0.05), but the difference disappeared by 2 years (P = 0.111). Cage subsidence occurred in 7.3% (3/41) and 7.3% (3/41) of the patients at 3 and 24 months, respectively, in the combined OLIF group, compared with 6.3% (2/32) and 15.6% (5/32), respectively, in the standalone OLIF group at the same time points (P = 0.287). There was no cage retropulsion in both groups at 2 years. The fusion rate was 85.4%(35/41) in the combined OLIF group and 84.4% (27/32) in the standalone OLIF group at 3 months(P = 0.669). At 24 months, the fusion rate was 100.0% in the combined OLIF group and 93.8% (30/32) in the standalone OLIF group (P = 0.066). CONCLUSION: Standalone OLIF may achieve equivalent clinical and radiological outcomes than OLIF combined with fixation for spondylolisthesis. The rate of complications was similar between the two groups. Patients who are osteoporotic might be better undergoing combined rather than standalone OLIF. The possibilty of proof lies within a future prospective study, preferably an RCT.

Quantitative analysis of paraspinal muscle atrophy after oblique lateral interbody fusion alone vs. combined with percutaneous pedicle screw fixation in patients with spondylolisthesis.

BACKGROUND: There is no available literature for comparison on muscle atrophy between the "stand-alone" oblique lateral interbody fusion (OLIF) and regular OLIF (i.e., combined with percutaneous pedicle screws fixation (PPSF) in patients with spondylolisthesis). This study aimed to identify changes in back muscle atrophy between the two surgeries. METHODS: This was a retrospective cohort study of patients who underwent OLIF or OLIF+PPSF at Beijing Jishuitan Hospital and Shanghai ChangZheng Hospital between 07/2014 and 10/2017. Computed tomography (CT) was used to measure functional cross-sectional area (FCSA) and fat infiltration percentage (FIP) of the multifidus and erector spinae before and 24 months after surgery. RESULT: There were no differences in FCSA and FIP between OLIF (n = 32) and OLIF+PPSF (n = 41) groups before surgery. In the OLIF group, the multifidus and erector spinae FCSA and FIP did not change at 24 months (FCSA: multifidus: from 8.59 ± 1.76 to 9.39 ± 1.74 cm2, P = 0.072; erector spinae: from 13.32 ± 1.59 to 13.55 ± 1.31 cm2, P = 0.533) (FIP: multifidus: from 15.91 ± 5.30% to 14.38 ± 3.21%, P = 0.721; erector spinae: from 11.63 ± 3.05% to 11.22 ± 3.12%, P = 0.578). In the OLIF+PPSF group, the multifidus and erector spinae FCSA decreased (multifidus: from 7.72 ± 2.69 to 5.67 ± 1.71 cm2, P < 0.001; erector spinae: from 12.60 ± 2.04 to 10.15 ± 1.82 cm2, P < 0.001), while the FIP increased (multifidus: from 16.13 ± 7.01% to 49.38 ± 20.54%, P < 0.001; erector spinae: from 11.93 ± 3.22% to 22.60 ± 4.99%, P < 0.001). The differences of FCSA and FIP between the two groups at 24 months were significant (all P < 0.001). The patients in the standalone OLIF group had better VAS back pain, and JOA scores than the patients in the OLIF combined group (all P < 0.05) at 1 week and 3 months after surgery. There were two cases (4.9%) of adjacent segment degeneration in the OLIF combined group, while there was no case in the OLIF alone group. CONCLUSIONS: Standalone OLIF had better clinical outcomes at 1 week and 3 months than OLIF+PPSF in patients with spondylolisthesis. OLIF may not result in paraspinal muscle atrophy at 24 months after surgery.

VNS implantation in a NF1 patient: massive nerve hypertrophy discovered intra-operatively preventing successful electrode placement. Case report.

For the vast majority of surgeons, no specific investigation is necessary before vagal nerve stimulation (VNS) implantation. We report our intraoperative unexpected finding of a massively enlarged vagus nerve in a patient with neurofibromatosis type 1 (NF1). The nerve hypertrophy prevented wrapping the coils of the helical electrode. The patient had no signs of vagus nerve dysfunction preoperatively (no hoarseness or dysphonia). This exceptional mishap is undoubtedly related to NF1-associated peripheral nerve sheath tumors. Even though it is not advisable to routinely perform any imaging prior to VNS, in such specific context, preoperative imaging work-up, especially cervical ultrasound, might be judicious to rule out any asymptomatic enlarged left vagus nerve.

Risk Factors of Intraoperative Dysglycemia in Elderly Surgical Patients.

BACKGROUNDː Dysglycemia is associated with adverse outcome including increased morbidity and mortality in surgical patients. Acute insulin resistance due to the surgical stress response is seen as a major cause of so-called stress hyperglycemia. However, understanding of factors determining blood glucose (BG) during surgery is limited. Therefore, we investigated risk factors contributing to intraoperative dysglycemia. METHODSː In this subgroup investigation of the BIOCOG study, we analyzed 87 patients of ≥ 65 years with tight intraoperative BG measurement every 20 min during elective surgery. Dysglycemia was defined as at least one intraoperative BG measurement outside the recommended target range of 80-150 mg/dL. Additionally, all postoperative BG measurements in the ICU were obtained. Multivariable logistic regression analysis adjusted for age, sex, American Society of Anesthesiologists (ASA) status, diabetes, type and duration of surgery, minimum Hemoglobin (Hb) and mean intraoperative norepinephrine use was performed to identify risk factors of intraoperative dysglycemia. RESULTSː 46 (52.9%) out of 87 patients developed intraoperative dysglycemia. 31.8% of all intraoperative BG measurements were detected outside the target range. Diabetes [OR 9.263 (95% CI 2.492, 34.433); p=0.001] and duration of surgery [OR 1.005 (1.000, 1.010); p=0.036] were independently associated with the development of intraoperative dysglycemia. Patients who experienced intraoperative dysglycemia had significantly elevated postoperative mean (p<0.001) and maximum BG levels (p=0.001). Length of ICU (p=0.007) as well as hospital stay (p=0.012) were longer in patients with dysglycemia. CONCLUSIONSː Diabetes and duration of surgery were confirmed as independent risk factors for intraoperative dysglycemia, which was associated with adverse outcome. These patients, therefore, might require intensified glycemic control. Increased awareness and management of intraoperative dysglycemia is warranted.

Smooth Muscle Cells in Pelvic Washings at Time of Benign Hysterectomy.

STUDY OBJECTIVE: To evaluate if smooth muscle cells can be detected in pelvic washings at the time of intact hysterectomy. DESIGN: A multicentered pilot cohort study (Canadian Task Force classification II-2). SETTING: Two academically affiliated tertiary referral centers. PATIENTS: Patients undergoing total hysterectomy for benign indications without morcellation by minimally invasive gynecologic surgeons were enrolled from January 2018 to July 2018. INTERVENTIONS: Pelvic washings were collected at 2 times during surgery: after abdominal entry and after vaginal cuff closure. Cell blocks were generated, and slides were stained using hematoxylin and eosin, smooth muscle actin, and desmin and interpreted by 1 expert pathologist at each institution. MEASUREMENTS AND MAIN RESULTS: Thirty-eight subjects were recruited; 3 subjects were excluded because of unplanned morcellation. Smooth muscle uterine cells were detected in 1 prewash specimen and 2 postwash specimens. The group with positive washings was noted to have longer procedure times (136 vs 114 minutes), lower blood loss (25 vs 86 mL), and higher uterine weight (242 vs 234 g) compared with negative washings group. CONCLUSION: Tissue dissemination of uterine cells may be possible at the time of hysterectomy. Larger prospective studies are needed to better describe the incidence of and risk factors for tissue dissemination.

Low-frequency ventilation during cardiopulmonary bypass for lung protection: A randomized controlled trial.

OBJECTIVE: Pulmonary dysfunction is a common complication in patients undergoing heart surgery. Current clinical practice does not include any specific strategy for lung protection. To compare the anti-inflammatory effects of low-frequency ventilation (LFV), as measured by nuclear factor κ-light-chain-enhancer of activated B cells (NF-κB) p65 pathway activation, for the entire cardiopulmonary bypass (CPB) vs both lungs left collapsed in patients undergoing coronary artery bypass grafting (CABG). METHODS: Two groups parallel randomized controlled trial. The primary outcome was inflammation measured by NF-κB p65 activation in pre- and post-CPB lung biopsies. Secondary outcomes were additional inflammatory markers in both biopsy tissue and blood. RESULTS: Thirty-seven patients were randomly allocated to LFV (18) and to both lungs left collapsed (19). The mean concentration of NF-κB p65 in the biopsies before chest closure (adjusted for pre-CPB concentration) was higher in the LFV group compared to both lungs left collapsed group but this was not significant (0.102, 95% confidence interval, -0.022 to 0.226, P = 0.104). There were no significant differences between groups in the other inflammatory markers measured in tissue and blood. CONCLUSIONS: In patients undergoing elective CABG, the use of LFV during CPB when compared to both lungs left collapsed does not seem to reduce inflammation in lung biopsies and blood.

Histological Comparison of Cold versus Hot Snare Resections of the Colorectal Mucosa.

BACKGROUND: Delayed postpolypectomy bleeding occurs more frequently after hot resection than after cold resection. OBJECTIVE: To elucidate the underlying mechanism, we performed a histological comparison of tissue after cold and hot snare resections. DESIGN: This is a prospective study, registered in the University Hospital Medical Information Network (UMIN000020104). SETTING: This study was conducted at Aizu Medical Center, Fukushima Medical University, Japan. PATIENTS: Fifteen patients scheduled to undergo resection of colorectal cancer were enrolled. INTERVENTION: On the day before surgery, 2 mucosal resections (hot and cold) of normal mucosa were performed on each patient using the same snare without saline injection. The difference was only the application of electrocautery or not. Resection sites were placed close to the cancer to be included in the surgical specimen. MAIN OUTCOME MEASURES: The primary outcome measure was the depth of destruction. Secondary outcome measures included the width of destruction, depth of the remaining submucosa, and number of vessels remaining at the resection sites. The number and diameter of vessels in undamaged submucosa were also evaluated. RESULTS: All cold resections were limited to the shallow submucosa, whereas 60% of hot resections advanced to the deep submucosa and 20% to the muscularis propria (p < 0.001). There was no significant difference in the width of destruction. The number of remaining large vessels after hot resections trended toward fewer (p = 0.15) with a decreased depth of remaining submucosa (p = 0.007). In the deep submucosa, the vessel diameter was larger (p < 0.001) and the number of large vessels was greater (p = 0.018). LIMITATIONS: Histological assessment was not blinded to the 2 reviewers. Normal mucosa was used instead of adenomatous tissue. CONCLUSIONS: Hot resection caused damage to deeper layers involving more large vessels. This may explain the mechanism for the reduced incidence of hemorrhage after cold snare polypectomy. See Video Abstract at http://links.lww.com/DCR/A631.

Cystoscopy at the time of incontinence and prolapse surgery.

PURPOSE OF REVIEW: This article provides an update on the use of cystoscopy at the time of prolapse and incontinence surgery. RECENT FINDINGS: Iatrogenic lower urinary tract injury is a known complication of antiincontinence procedures and surgical repair of pelvic organ prolapse. Intraoperative cystoscopy improves detection of lower urinary tract injuries in women undergoing pelvic floor surgery. The pelvic surgeon has a number of agents available to aid in the cystoscopic visualization of ureteral efflux. When injuries of the urinary tract are identified and treated intraoperatively, there is decreased morbidity, lower healthcare costs, and a lower risk of litigation than when detection is delayed. Therefore, many organizations, including the American College of Obstetricians and Gynecologists (ACOG), the American Urogynecologic Society (AUGS), and the American Urological Association (AUA) recommend cystoscopy at the time of pelvic floor surgery. SUMMARY: Cystoscopy should be universally employed at the time of prolapse and incontinence surgery, except in instances of isolated repair of the posterior compartment.

Detecting accidental punctures and lacerations during cholecystectomy in large datasets: Two methods of analysis.

BACKGROUND: After the Institute of Medicine (IOM) report To Err Is Human highlighted the impact of medical errors, the Agency for Healthcare Research and Quality (AHRQ) developed Patient-Safety Indicators (PSI) to improve quality by identifying potential inpatient safety problems. PSI-15 was created to study accidental punctures and lacerations (APL), but PSI-15 may underestimate APLs in populations of patients. This study compares PSI-15 with a more inclusive approach using a novel composite of secondary diagnostic and procedural codes. METHODS: We used Nationwide Inpatient Sample (NIS) data (2000-2012) from AHRQ's Healthcare Cost and Utilization Project (H-CUP). We analyzed PSI-15-positive and -negative cholecystectomies. Cross tabulations identified codes that were significantly more frequent among PSI-15-positive cases; these secondary diagnostic and procedural codes were selected as candidate members of a composite marker (CM) of APL. We chose cholecystectomy patients for study because this is one of the most common general operations, and the large size of NIS allows for meaningful analysis of infrequent occurrences such as APL rates. RESULTS: CM identified 1.13 times more APLs than did PSI-15. Patients with CM-detected APLs were significantly older and had worse mortality, comorbidities, lengths of stay, and charges than those detected with PSI-15. Further comparison of these two approaches revealed that time-series analysis for both APL markers revealed parallel trends, with inflections in 2007, and lowest APL rates in July. CONCLUSIONS: Although CM may yield more false positives, it appears more inclusive, identifying more clinically significant APLs, than PSI-15. Both measures presented similar trends over time, arguing against inflation in PSI-15 reporting. While arguably less specific, CM may increase sensitivity for detecting APL events during cholecystectomies. These results may inform the interpretation of other large population studies of APLs following abdominal operations.

[Non-functioning gallbladder as a risk factor for bile ducts injury during laparoscopic cholecystectomy]. / Nefunktsioniruiushchii zhelchnyi puzyr' kak faktor riska travm zhelchnykh protokov pri laparoskopicheskoi kholetsistéktomii.

AIM: To analyze the effect of gallbladder's morpho-functional changes as a risk factor for injury of extrahepatic bile ducts during cholecystectomy. MATERIAL AND METHODS: Laparoscopic cholecystectomy was performed in 20 564 patients. There were 147 64 (71.8%) patients with chronic gallbladder inflammation and 5800 (28.2%) - with acute process. It was performed a retrospective analysis of the incidence and causes of intraoperative trauma of extrahepatic bile ducts and bile outflow. Two groups of comparison were distinguished: acute calculous cholecystitis and chronic inflammation. RESULTS: There were 93 (0.04%) complications followed by bile outflow (55 (0.94%) in the 1st group and 38 (0.25%) in the 2nd group). Marginal injury of the ducts was interoperatively detected in 5 patients of group 1 and 3 patients of 2 groups. In postoperative period it was found in 6 patients of the 1st group due to electric trauma of common bile duct. Complete transection of common bile duct occurred in 10 (8.8%) cases, while chronic calculous cholecystitis was observed in 8 of them. At the same time, in 6 patients these were surgical interventions in scleroatrophic gallbladder. As a results, we determined the forms of non-functioning gallbladder with morphofunctional changes which promote trauma of extrahepatic bile ducts. CONCLUSION: Long-term non-functioning gallbladder leads to cicatricial and adhesive processes in its wall and surrounding tissues that significantly complicates cholecystectomy and increases the risk of bile ducts trauma. Scleroatrophic gallbladder is the most dangerous which occurs in 4.1% of patients with chronic calculous cholecystitis. Further trials are advisable to develop optimal therapeutic and diagnostic tactics for various forms of long-term non-functioning gallbladder.

Crotalus helleri venom preconditioning reduces postoperative cerebral edema and improves neurological outcomes after surgical brain injury.

INTRODUCTION: Postoperative cerebral edema is a devastating complication in neurosurgical patients. Loss of blood-brain barrier integrity has been shown to lead to the development of brain edema following neurosurgical procedures. The aim of this study was to evaluate preconditioning with Crotalus helleri venom (Cv-PC) as a potential preventive therapy for reducing postoperative brain edema in the rodent SBI model. C. helleri venom is known to contain phospholipase A2 (PLA2), an enzyme upstream to cyclooxygenase-2 (COX-2) in the inflammatory cascade, acts to increase the production of inflammatory mediators, such as prostaglandins. We hypothesize that Cv-PC will downregulate the response of the COX-2 pathway to injury, thereby reducing the inflammatory response and the development of brain edema after SBI. MATERIALS AND METHODS: 75 male Sprague Dawley rats (280-330g) were divided to the following groups-naïve+vehicle, naïve+Cv-PC, sham, vehicle, Cv-PC, Cv-PC+NS398 (COX-2 inhibitor). Vehicle preconditioned and Cv-PC animals received either three daily subcutaneous doses of saline or C. helleri venom at 72h, 48h, and 24h prior to surgery. In Cv-PC+NS398 animals, NS398 was administered intraperitoneally 1h prior to each Cv-PC injection. Sham-operated animals received craniotomy only, whereas SBI animals received a partial right frontal lobectomy. Neurological testing and brain water content were assessed at 24h and 72h after SBI; COX-2 and PGE2 expression was assessed at 24h postoperatively by Western blot and immunohistochemistry, respectively. RESULTS: At 24h after SBI, the vehicle-treated animals were observed to have increased brain water content (83.1±0.2%) compared to that of sham animals (80.2±0.1%). The brain water content of vehicle-treated animals at 72h post-SBI was elevated at 83.3±0.2%. Cv-PC-treated animals with doses of 10% LD50 had significantly reduced brain water content of 81.92±0.7% and 81.82±0.3% at 24h and 72h, respectively, after SBI compared to that of vehicle-treated animals, while Cv-PC with 5% LD50 doses showed brain water content that trended lower but did not reach statistical significance. At 24h and 72h post-SBI, Cv-PC-treated animals had significantly higher neurological score than vehicle-treated animals. The COX-2 over-expression characterized in SBI was attenuated in Cv-PC-treated animals; NS398 reversed the protective effect of Cv-PC on COX-2 expression. Cv-PC tempered the over-expression of the inflammatory marker PGE2. CONCLUSION: Our findings indicate that Cv-PC may provide a promising therapy for reducing postoperative edema and improving neurological function after neurosurgical procedures.

Functional role of inflammation in the surgical injury induced vascular remodeling of male albino rats.

Our present study investigates the cellular and molecular inflammatory events in male albino rat arterial injury. Male albino rats were subjected to longitudinal incision and carotid artery clamping for the duration of 45 days. Heat shock protein (HSP) 27, HSP70, HSP47 and Nuclear Factor kappa B (NF-κB) expressions were determined by qPCR and Western blot method. The morphology of vessel wall alteration was studied by the light microscopy. The expression of NF-κB was found to be increased after ten days of carotid artery injury. The qPCR and Western blot analysis showed elevation in HSP47, HSP27, and HSP70 expression, ten days following the surgical injury. The neointima-formation and the media layer discontinuity were evidenced by light microscopy. The dendritic-like cells were in close contact with the lymphocytes. Our study reports that the surgical injury induces an inflammatory response through the increased NF-κB and HSPs expression.

Stray energy transfer during endoscopy.

INTRODUCTION: Endoscopy is the standard tool for the evaluation and treatment of gastrointestinal disorders. While the risk of complication is low, the use of energy devices can increase complications by 100-fold. The mechanism of increased injury and presence of stray energy is unknown. The purpose of the study was to determine if stray energy transfer occurs during endoscopy and if so, to define strategies to minimize the risk of energy complications. METHODS AND PROCEDURES: A gastroscope was introduced into the stomach of an anesthetized pig. A monopolar generator delivered energy for 5 s to a snare without contacting tissue or the endoscope itself. The endoscope tip orientation, energy device type, power level, energy mode, and generator type were varied to mimic in vivo use. The primary outcome (stray current) was quantified as the change in tissue temperature (°C) from baseline at the tissue closest to the tip of the endoscope. Data were reported as mean ± standard deviation. RESULTS: Using the 60 W coag mode while changing the orientation of the endoscope tip, tissue temperature increased by 12.1 ± 3.5 °C nearest the camera lens (p < 0.001 vs. all others), 2.1 ± 0.8 °C nearest the light lens, and 1.7 ± 0.4 °C nearest the working channel. Measuring temperature at the camera lens, reducing power to 30 W (9.5 ± 0.8 °C) and 15 W (8.0 ± 0.8 °C) decreased stray energy transfer (p = 0.04 and p = 0.002, respectively) as did utilizing the low-voltage cut mode (6.6 ± 0.5 °C, p < 0.001). An impedance-monitoring generator significantly decreased the energy transfer compared to a standard generator (1.5 ± 3.5 °C vs. 9.5 ± 0.8 °C, p < 0.001). CONCLUSION: Stray energy is transferred within the endoscope during the activation of common energy devices. This could result in post-polypectomy syndrome, bleeding, or perforation outside of the endoscopist's view. Decreasing the power, utilizing low-voltage modes and/or an impedance-monitoring generator can decrease the risk of complication.

Insertion forces and intracochlear trauma in temporal bone specimens implanted with a straight atraumatic electrode array.

The aim of the study was to evaluate insertion forces during manual insertion of a straight atraumatic electrode in human temporal bones, and post-implantation histologic evaluation of the samples to determine whether violation of intracochlear structures is related to insertion forces. In order to minimize intracochlear trauma and preserve residual hearing during cochlear implantation, knowledge of the insertion forces is necessary. Ten fresh frozen human temporal bones were prepared with canal wall down mastoidectomy. All samples were mounted on a one-axis force sensor. Insertion of a 16-mm straight atraumatic electrode was performed from different angles to induce "traumatic" insertion. Histologic evaluation was performed in order to evaluate intracochlear trauma. In 4 of 10 samples, dislocation of the electrode into scala vestibuli was observed. The mean insertion force for all 10 procedures was 0.003 ± 0.005 N. Insertion forces measured around the site of dislocation to scala vestibuli in 3 of 4 samples were significantly higher than insertion forces at the same location of the cochleae measured in samples without trauma (p < 0.04). Mean force during the whole insertion process of the straight atraumatic electrode is lower than reported by other studies using longer electrodes. Based on our study, insertion forces leading to basilar membrane trauma may be lower than the previously reported direct rupture forces.

[LAPAROSCOPIC PLASTY OF INGUINAL HERNIAS].

Laparoscopic hernioplasty, of them in 19 - for recurrence of hernia after auto- (in 10) and alloplasty in accordance to Liechtenstein procedure (in 9), and in 11, suffering bilateral hernias - were performed in 2011-2016 yrs in 149 patients. All the patients are alive. Complications have occurred in 21 patients. The main technical complexities have occurred in injury of upper epigastric vessels. Оperative interventions, using laparoscopic procedures are effective, pathogenetically substantiated, guaranteeing comfortable course of postoperative period and possibility of early rehabilitation of the patients.

[АNESTHESIOLOGICAL SUPPORT OF PANCREATICODUODENAL RESECTION].

Efficacy of combined and potentiated methods of anesthesiological support of operative interventions on the organs of pancreatoduodenal zone was estimated. In 43 consequently treated patients operative interventions was performed for malignant tumors and fibrous-degenerative changes of pancreatic gland. Efficacy and interchangeability of various methods of anesthesiological support for reduction of the operative risk stage and the risk of intraoperative iatrogenic injury was studied.

[ОPTIMIZATION OF SURGICAL TREATMENT OF HEMORRHOIDAL DISEASE STAGES III-IV].

The treatment results in patients, suffering chronic hemorrhoidal disease stages III- IV, in accordance to the elaborated method of hemorrhoidectomy, using radio-wave scalpel «Surgitron TM¼ with further welding of vascular pedicle, applying high-frequency electrocoagulator ЕК-301М1, are presented. In the patients, оperated on in accordance to the method proposed, the intraoperative complications rate and the blood loss severity were essentially lesser than in a comparison group. Owing an adequate level of surgical skills, the operative treatment method elaborated guarantees the reduction of early and late postoperative morbidity, rapid coming back to routine way of living postoperatively.

Acute Bowel Injury due to Cryoablation for Renal Cell Carcinoma: Correlated Radiologic and Pathologic Findings.

An 87-year-old Japanese man underwent percutaneous cryoablation (PCA) therapy for his renal cell tumor. We displaced the colon from the tumor using hydrodissection. Computed tomography (CT) immediately after PCA was indicative of iceball extension to the colon wall, and a discontinuous enhancement of the colon wall was observed. We therefore performed an emergency surgery. On laparotomy, we observed a dark-purple area on the affected area of the colon, and the resected specimen showed focal, deep ulceration on the mucosal surface. Photomicrography revealed mucosal necrosis, submucosal hemorrhage, and necrotic foci in the muscularis propria, corresponding to the discontinuous colon wall enhancement on CT and the deep ulceration and dark-purple area on laparotomy. He recovered from surgery and was discharged without any complications.

[[Video-assisted pulmonary resection application for pulmonary tuberculosis].]

Results of application of video-assisted (video-assisted thoracic surgery VATS) pulmonary resection for pulmonary tuberculosis in 63 patients in 2008 - 2016 yrs were analyzed. Typical lobectomy was done in 28 (44.4%) patients, pulmonectomy - in 1 (1.6%), lower bilobectomy - in 1 (1.6%), combined resection of upper lobe and the Cv segment - in 1 (1.6%), typical segmentectomy - in 23 (36.5%), atypical one - in 9 (14.3%). Intraoperative complications have occurred in 4,(6.3%) patients, and postop- erative - in 8 (12.7%). Total efficacy of performance of pulmonary VATS-resection have constituted 98.4%. VATS-pulmonary resection is a miniinvasive and perspective treatment procedure. Meticulous selection of patients is needed for such intervention be applied.